Provider Demographics
NPI:1013537067
Name:CANCILLA, MARTHA ANNA (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANNA
Last Name:CANCILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:ANNA
Other - Last Name:CHODABA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1120 W MICHIGAN ST # CL642
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-278-2686
Mailing Address - Fax:
Practice Address - Street 1:1120 W MICHIGAN ST # CL642
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01089881A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program