Basic Information
| Provider Information | |||||||||
| NPI: | 1750388054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | GRACIELA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328393716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4078946872 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 S JOHN YOUNG PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328393716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073986470 | ||||||||
| FaxNumber: | 4078946872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME0060897 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 371426800 | 05 | FL | MEDICAID |