Provider Demographics
NPI:1255331120
Name:MARTINEZ, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0387
Mailing Address - Fax:
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2224
Practice Address - Country:US
Practice Address - Phone:817-321-0387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH82352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138696314Medicaid
TX1386963-16Medicaid
TX138696310Medicaid
TX138696314Medicaid
TXTXB120619Medicare UPIN
TX89368RMedicare ID - Type Unspecified'OTHER' COUNTIES
TX1386963-16Medicaid