Provider Demographics
NPI:1780894113
Name:MARTINEZ, NICOLE MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MICHELLE
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 1:845 N NEW BALLAS CT STE 360
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7124
Mailing Address - Country:US
Mailing Address - Phone:314-219-1247
Mailing Address - Fax:
Practice Address - Street 1:845 N NEW BALLAS CT STE 360
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7124
Practice Address - Country:US
Practice Address - Phone:314-219-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0250208600000X
NY265640208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03504267Medicaid
PA102784987Medicaid
8L5159Medicare PIN
NY03504267Medicaid