Provider Demographics
NPI:1104868041
Name:STILLMAN, MARTIN J (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:STILLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE (P7)
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1829
Mailing Address - Country:US
Mailing Address - Phone:612-873-2300
Mailing Address - Fax:612-904-4261
Practice Address - Street 1:701 PARK AVE (P7)
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1829
Practice Address - Country:US
Practice Address - Phone:612-873-2300
Practice Address - Fax:612-904-4261
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110187100Medicaid
110007568Medicare ID - Type Unspecified
MN110187100Medicaid