Provider Demographics
NPI:1407829203
Name:MARTIN, DELLICE (MD)
Entity Type:Individual
Prefix:DR
First Name:DELLICE
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 1:300 1ST CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2844
Mailing Address - Country:US
Mailing Address - Phone:636-947-5162
Mailing Address - Fax:636-949-7273
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:636-947-5162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101041207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208951426Medicaid
MO020012671Medicare PIN
MOG65280Medicare UPIN