Provider Demographics
NPI:1528284858
Name:MARTINEZ, EDGARD REINALDO SR (MS PH D)
Entity type:Individual
Prefix:DR
First Name:EDGARD
Middle Name:REINALDO
Last Name:MARTINEZ
Suffix:SR
Gender:M
Credentials:MS PH D
Other - Prefix:DR
Other - First Name:EDGARD
Other - Middle Name:REINALDO
Other - Last Name:MARTINEZ
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MS PH D
Mailing Address - Street 1:PO BOX 1464
Mailing Address - Street 2:P.O. BOX 1464
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-1464
Mailing Address - Country:US
Mailing Address - Phone:787-632-5909
Mailing Address - Fax:787-860-1463
Practice Address - Street 1:GENERAL VALERO AVENUE
Practice Address - Street 2:SUITE 313A SECOND LEVEL
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-1464
Practice Address - Country:US
Practice Address - Phone:787-632-5909
Practice Address - Fax:787-860-1463
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR689103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR689 LICENCEOtherCLINICAL PSYCHOLOGIST