Provider Demographics
NPI:1962280495
Name:MARTINEZ, MARVIN JAVIER
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:JAVIER
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9999 NW 9TH STREET CIR APT 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5155
Mailing Address - Country:US
Mailing Address - Phone:786-365-1165
Mailing Address - Fax:
Practice Address - Street 1:9999 NW 9TH STREET CIR APT 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-5155
Practice Address - Country:US
Practice Address - Phone:786-365-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4000175523363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical