Basic Information
| Provider Information | |||||||||
| NPI: | 1457356289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 639 N MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427011931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Practice Location | |||||||||
| Address1: | 639 N MULBERRY ST | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427011931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707374600 | ||||||||
| FaxNumber: | 2707371722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 03/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 30130 | KY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64301302 | 05 | KY | MEDICAID |