Basic Information
| Provider Information | |||||||||
| NPI: | 1043240864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ITALO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 734812 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753734812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589500 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 DORA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782121516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103588255 | ||||||||
| FaxNumber: | 2106448025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD12082 | RI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.