1689782294 NPI number — CARLOS ROBERTO MARTINEZ I.D.C.

Table of content: CARLOS ROBERTO MARTINEZ I.D.C. (NPI 1689782294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689782294 NPI number — CARLOS ROBERTO MARTINEZ I.D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ
Provider First Name:
CARLOS
Provider Middle Name:
ROBERTO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
I.D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689782294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1829B TERRIER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POINT MUGU
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-889-5848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 1ST ST
Provider Second Line Business Practice Location Address:
BLDG 1402
Provider Business Practice Location Address City Name:
PORT HUENEME
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93043-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-982-6496
Provider Business Practice Location Address Fax Number:
805-815-3753
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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