Provider Demographics
NPI:1306257076
Name:MARTINEZ, SONIA (LDO)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3109
Mailing Address - Country:US
Mailing Address - Phone:973-350-9557
Mailing Address - Fax:973-350-1051
Practice Address - Street 1:677 MOUNT PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-350-9557
Practice Address - Fax:973-350-1051
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00348600156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1740483502Medicaid