Basic Information
| Provider Information | |||||||||
| NPI: | 1396186961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ BRENES | ||||||||
| FirstName: | LOURDES | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405684814 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 MATTHEW ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403747701 | ||||||||
| FaxNumber: | 7403747701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME127201 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.135338 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0336673 | 05 | OH | MEDICAID |