Provider Demographics
NPI:1992859599
Name:MARTINEZ, FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:MARTINEZ
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 663
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0663
Mailing Address - Country:US
Mailing Address - Phone:912-535-5555
Mailing Address - Fax:912-537-0865
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-535-5555
Practice Address - Fax:912-537-0865
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA755529465AMedicaid
GA511I110088Medicare PIN
GA755529465AMedicaid