Provider Demographics
NPI:1265019392
Name:MARTINEZ, IVAN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
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 1:500 S ANAHEIM HILLS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4759
Mailing Address - Country:US
Mailing Address - Phone:714-974-1717
Mailing Address - Fax:
Practice Address - Street 1:500 S ANAHEIM HILLS RD STE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4759
Practice Address - Country:US
Practice Address - Phone:714-974-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA195722207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program