Provider Demographics
NPI:1003428103
Name:MARTIN, ADOLFO (PTA)
Entity type:Individual
Prefix:
First Name:ADOLFO
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15271 NW 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2422
Mailing Address - Country:US
Mailing Address - Phone:305-456-6700
Mailing Address - Fax:786-870-5196
Practice Address - Street 1:15271 NW 60TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2422
Practice Address - Country:US
Practice Address - Phone:305-456-6700
Practice Address - Fax:786-870-5196
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26689225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM635-013-77-448-0Medicaid