Provider Demographics
NPI:1245204122
Name:MARTIN, LISA (MD MPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 RAYMOND DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9789
Mailing Address - Country:US
Mailing Address - Phone:630-717-2300
Mailing Address - Fax:630-717-9638
Practice Address - Street 1:636 RAYMOND DR
Practice Address - Street 2:SUITE 205
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-717-2300
Practice Address - Fax:630-717-9638
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36102079208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36102079Medicaid
IL36102079Medicaid
H80107Medicare UPIN