Provider Demographics
NPI:1942229562
Name:MARTIN, ENRICO LOPEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:ENRICO
Middle Name:LOPEZ
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9170
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-9170
Mailing Address - Country:US
Mailing Address - Phone:515-633-3600
Mailing Address - Fax:515-633-3838
Practice Address - Street 1:5880 UNIVERSITY AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8209
Practice Address - Country:US
Practice Address - Phone:515-633-3600
Practice Address - Fax:515-288-0840
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37512207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71046OtherBC/BS OF IOWA
IL101 15504OtherB/C B/S OF ILLINOIS
IA1942229562Medicaid
GACB0709/060070355OtherRR MEDICARE GROUP #/PIN
IL036107290 1Medicaid
ILG56097Medicare UPIN
IA1942229562Medicaid
IL737950/L94557Medicare ID - Type UnspecifiedMEDICARE GROUP #/PIN