Provider Demographics
NPI:1992825087
Name:SPORTS MED MD, INC
Entity Type:Organization
Organization Name:SPORTS MED MD, INC
Other - Org Name:RONICA MARTINEZ, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONICA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-823-6474
Mailing Address - Street 1:PO BOX 4472
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91222-0472
Mailing Address - Country:US
Mailing Address - Phone:818-823-6474
Mailing Address - Fax:818-337-7456
Practice Address - Street 1:22633 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1416
Practice Address - Country:US
Practice Address - Phone:818-444-5100
Practice Address - Fax:818-337-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79490261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861415853OtherNPI
CA1861415853OtherNPI