Basic Information
| Provider Information | |||||||||
| NPI: | 1356411375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 HICKSVILLE RD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117143471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165766106 | ||||||||
| FaxNumber: | 5165765801 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633010 | ||||||||
| FaxNumber: | 5166633026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 25MA06683400 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02961195 | 05 | NY | MEDICAID |