Provider Demographics
NPI:1053454926
Name:MARTIN, TEDJITOU (PA)
Entity Type:Individual
Prefix:MS
First Name:TEDJITOU
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6436 ROOSEVELT RD
Mailing Address - Street 2:307
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2163
Mailing Address - Country:US
Mailing Address - Phone:708-655-9606
Mailing Address - Fax:
Practice Address - Street 1:6436 ROOSEVELT RD
Practice Address - Street 2:307
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2163
Practice Address - Country:US
Practice Address - Phone:708-655-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002895363A00000X
IL085-002895207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL701330002Medicare PIN