Provider Demographics
NPI:1306608955
Name:MARTINEZ, GUSTAVO KENNEDY (PT, DPT)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:KENNEDY
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W LIVEOAK ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4227
Mailing Address - Country:US
Mailing Address - Phone:580-649-4378
Mailing Address - Fax:
Practice Address - Street 1:1975 TICE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2201
Practice Address - Country:US
Practice Address - Phone:580-649-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist