Provider Demographics
NPI:1386296630
Name:MARTINEZ, MARVIN LAWRENCE VIVAS (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:MARVIN LAWRENCE
Middle Name:VIVAS
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 1:52 TOLER LOOP APT 2
Mailing Address - Street 2:
Mailing Address - City:BELFRY
Mailing Address - State:KY
Mailing Address - Zip Code:41514-8692
Mailing Address - Country:US
Mailing Address - Phone:917-584-5629
Mailing Address - Fax:
Practice Address - Street 1:260 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSON
Practice Address - State:KY
Practice Address - Zip Code:41503-4072
Practice Address - Country:US
Practice Address - Phone:606-237-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007402261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY007402OtherKENTUCKY BOARD OF PHYSICAL THERAPY