Provider Demographics
NPI:1770566614
Name:MARTINEZ, M LETICIA (RD)
Entity type:Individual
Prefix:
First Name:M
Middle Name:LETICIA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-792-9890
Mailing Address - Fax:520-884-9287
Practice Address - Street 1:839 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2819
Practice Address - Country:US
Practice Address - Phone:520-670-3904
Practice Address - Fax:520-670-3816
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ637712Medicaid
AZ68199Medicare ID - Type Unspecified
AZ637712Medicaid