Provider Demographics
NPI:1053711408
Name:MARTINEZ, LEO I (NBSTSA 151273)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:MARTINEZ
Suffix:I
Gender:M
Credentials:NBSTSA 151273
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 BAYOU VISTA DR
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-5983
Mailing Address - Country:US
Mailing Address - Phone:713-269-5817
Mailing Address - Fax:
Practice Address - Street 1:602 BAYOU VISTA DR
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536
Practice Address - Country:US
Practice Address - Phone:713-269-5817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
TXSA00684246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-1701695OtherEIN