Provider Demographics
NPI:1205477783
Name:BENSON MARTINEZ, CARLOS THOMAS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:THOMAS
Last Name:BENSON MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12577 SE RIVER RD APT 139
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-8007
Mailing Address - Country:US
Mailing Address - Phone:617-301-0447
Mailing Address - Fax:
Practice Address - Street 1:12655 SW CENTER ST STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1600
Practice Address - Country:US
Practice Address - Phone:617-301-0447
Practice Address - Fax:503-828-3401
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003795175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000003795OtherTHW CERTIFICATION #