Provider Demographics
NPI:1053429894
Name:MARTINEZ, ANGEL R (PHD)
Entity type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:R
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-4210
Mailing Address - Country:US
Mailing Address - Phone:727-319-3020
Mailing Address - Fax:717-319-3040
Practice Address - Street 1:10333 SEMINOLE BLVD
Practice Address - Street 2:SUITE # 6
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-4210
Practice Address - Country:US
Practice Address - Phone:727-319-3020
Practice Address - Fax:727-319-3040
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH503103TC0700X, 103TC2200X
FL1958103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003798Medicaid
FL313215OtherAMERIGROUP
NHRE3099Medicare ID - Type Unspecified