Provider Demographics
NPI:1154589950
Name:MARTINEZ GRULLON, JUAN CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:MARTINEZ GRULLON
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 1:1250 8TH AVE
Mailing Address - Street 2:STE 265
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4124
Mailing Address - Country:US
Mailing Address - Phone:682-200-8580
Mailing Address - Fax:682-200-8581
Practice Address - Street 1:1250 8TH AVE STE 265
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4124
Practice Address - Country:US
Practice Address - Phone:682-200-8580
Practice Address - Fax:682-200-8581
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD448858208200000X
TXT3999208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0182590Medicaid
OH0182590Medicaid