Provider Demographics
NPI:1275761603
Name:MARTENS, MATTHEW L (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:MARTENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W ILLINOIS ST APT 501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 W 203RD ST STE 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1182
Practice Address - Country:US
Practice Address - Phone:708-679-2120
Practice Address - Fax:708-503-3230
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A10803208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036129770OtherILLINOIS
CA20A10803OtherCA MEDICAL LICENSE
IL203979048OtherMEDICARE PTAN