Provider Demographics
NPI:1215345772
Name:MARTINEZ, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
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:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NEW MEXICO
Mailing Address - Zip Code:87125
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6100 PAN AMERICAN FREEWAY NE STE 200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NEW MEXICO
Practice Address - Zip Code:87109
Practice Address - Country:MX
Practice Address - Phone:505-823-8282
Practice Address - Fax:505-823-8275
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA001361491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine