Provider Demographics
NPI:1134198112
Name:DE LEON-MARTINEZ, CARMEN M (MD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:M
Last Name:DE LEON-MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5010 HOLLYWOOD BLVD 100B
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6557
Mailing Address - Country:US
Mailing Address - Phone:954-967-0028
Mailing Address - Fax:954-967-8141
Practice Address - Street 1:18610 NW 87TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3519
Practice Address - Country:US
Practice Address - Phone:305-829-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20194Medicare ID - Type UnspecifiedNUM DE PROVEEDOR MEDICARE