Provider Demographics
NPI:1952949521
Name:MARTINEZ, GEORGE J (RT (R))
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:J
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12516 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-3844
Mailing Address - Country:US
Mailing Address - Phone:303-525-3847
Mailing Address - Fax:
Practice Address - Street 1:12516 BRYANT ST
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-3844
Practice Address - Country:US
Practice Address - Phone:303-525-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONONEMedicaid