Provider Demographics
NPI:1316920952
Name:MARTINEZ, ALFONSO (PHD)
Entity type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 MOUNT VERNON TRCE
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2641
Mailing Address - Country:US
Mailing Address - Phone:770-629-4575
Mailing Address - Fax:770-629-4575
Practice Address - Street 1:6000 SHAKERAG HL
Practice Address - Street 2:SUITE 216
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6523
Practice Address - Country:US
Practice Address - Phone:770-632-1088
Practice Address - Fax:770-632-2088
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5814103T00000X
GAPSY3117103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54463YMedicare PIN