Provider Demographics
NPI:1154637387
Name:MARTINEZ, DOMINGO CARLO DISRAELI (DPT, CSCS)
Entity type:Individual
Prefix:DR
First Name:DOMINGO CARLO
Middle Name:DISRAELI
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:DOMINGO-CARLO
Other - Middle Name:DISRAELI
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1534 EUCLID ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3331
Mailing Address - Country:US
Mailing Address - Phone:626-260-4755
Mailing Address - Fax:
Practice Address - Street 1:1534 EUCLID ST APT 2
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3331
Practice Address - Country:US
Practice Address - Phone:626-260-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist