Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | 01049611 | IN |
NPI | 1043262769 |
---|---|
Provider Name | Manuel A Martinez |
First Address | Fort Wayne, IN 46845-1701 |
Second Address | Fort Wayne, IN 46845-1672 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 02/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000576779 | ANTHEM (01) | IN |
000000670274 | ANTHEM (01) | IN |
200341260 | (05) | IN |
H46037 | (02) | IN |
P00685788 | MEDICARE RR (01) | IN |