Provider Demographics
NPI:1871786335
Name:MARTINEZ, ELLIOTT O (IDC)
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:O
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S.R. 108 BLDG 3005
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:93517
Mailing Address - Country:US
Mailing Address - Phone:760-932-1616
Mailing Address - Fax:760-932-1623
Practice Address - Street 1:STATE ROAD 108 BLDG 3005
Practice Address - Street 2:DEWERT BRANCH HEALTH CLINIC
Practice Address - City:BRIDGEPORT
Practice Address - State:CA
Practice Address - Zip Code:93517-7777
Practice Address - Country:US
Practice Address - Phone:760-932-1616
Practice Address - Fax:760-932-1623
Is Sole Proprietor?:No
Enumeration Date:2007-08-19
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman