Provider Demographics
NPI:1326009705
Name:SPAIN, MARTA T (MD)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:T
Last Name:SPAIN
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:1701 CURTIS RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9678
Practice Address - Country:US
Practice Address - Phone:217-326-1477
Practice Address - Fax:217-326-1110
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45526207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO018601OtherKAISER COMMERCIAL NUMBER
CO15273865Medicaid
COC809884Medicare PIN
COCOA105241Medicare PIN
CO15273865Medicaid
CO018601OtherKAISER COMMERCIAL NUMBER
CAE85480Medicare UPIN