1124115514 NPI number — EDWIN R MARTINEZ MEJIAS MD

Table of content: EDWIN R MARTINEZ MEJIAS MD (NPI 1124115514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124115514 NPI number — EDWIN R MARTINEZ MEJIAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINEZ MEJIAS
Provider First Name:
EDWIN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTINEZ
Provider Other First Name:
EDWIN
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1124115514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
483 N SEMORAN BLVD
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32792-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-571-1056
Provider Business Mailing Address Fax Number:
321-274-0322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7806 LAKE UNDERHILL RD STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-8232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-601-0888
Provider Business Practice Location Address Fax Number:
407-601-0931
Provider Enumeration Date:
10/06/2006

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: 207RC0000X , with the licence number:  L3390 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: ME95229 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0038QR . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 060070478 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 147494201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F4950 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 104383400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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