Provider Demographics
NPI:1023152824
Name:MARTINEZ, MICHAEL R (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 BENT WAY
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7614
Mailing Address - Country:US
Mailing Address - Phone:303-678-3237
Mailing Address - Fax:303-678-3225
Practice Address - Street 1:2345 BENT WAY
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7614
Practice Address - Country:US
Practice Address - Phone:303-678-3237
Practice Address - Fax:303-678-3225
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31932208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01319326Medicaid
007019OtherKAISER-COMMERCIAL NUMBER
007019OtherKAISER-COMMERCIAL NUMBER
COCK10412Medicare PIN