1023569639 NPI number — MARIO ALBERTO MARTINEZ

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023569639 NPI number — MARIO ALBERTO MARTINEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIO ALBERTO MARTINEZ
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1023569639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQ
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-743-3900
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALZADA INDEPENDENCIA E5
Provider Second Line Business Practice Location Address:
CENTRO CIVICO
Provider Business Practice Location Address City Name:
MEXICALI
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
21000
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
686-248-1806
Provider Business Practice Location Address Fax Number:
866-272-6924
Provider Enumeration Date:
10/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
686-248-1806

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  9411925 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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