Provider Demographics
NPI:1720543366
Name:MARTINEZ, EDWARD RAFAEL
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:RAFAEL
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 ALEXANDER AVENUE
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-7307
Mailing Address - Country:US
Mailing Address - Phone:321-914-9665
Mailing Address - Fax:321-914-9665
Practice Address - Street 1:12724 GRAN BAY PARKWAY
Practice Address - Street 2:410
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid
FL17198Other17198