Provider Demographics
NPI:1114033669
Name:MARTIN, ALLISON (MD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20110 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1030
Mailing Address - Country:US
Mailing Address - Phone:708-747-7960
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:20110 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1030
Practice Address - Country:US
Practice Address - Phone:708-747-7960
Practice Address - Fax:708-503-3993
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32020900Medicaid
WIF50197Medicare UPIN