Provider Demographics
NPI:1962808303
Name:JUAN CARLOS MARTINEZ-MORENO MD PC
Entity type:Organization
Organization Name:JUAN CARLOS MARTINEZ-MORENO MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:MARTINEZ-MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-826-2816
Mailing Address - Street 1:3017 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 90
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1941
Mailing Address - Country:US
Mailing Address - Phone:702-826-2816
Mailing Address - Fax:702-826-2813
Practice Address - Street 1:3017 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 90
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1941
Practice Address - Country:US
Practice Address - Phone:702-826-2816
Practice Address - Fax:702-826-2813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV208100000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114118676Medicaid