Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | 503 | NH |
N | 103TC0700X | Clinical Psychologist | 503 | NH |
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 1958 | FL |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 503 | NH |
NPI | 1053429894 |
---|---|
Provider Name | Dr. Angel R Martinez |
First Address | Largo, FL 33778-4210 |
Second Address | Largo, FL 33778-4210 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2006 |
Last Update Date | 30/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
30003798 | (05) | NH |
313215 | AMERIGROUP (01) | FL |