Provider Demographics
NPI:1497732499
Name:MARTIN, ROBERT P (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 WEST DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950
Mailing Address - Country:US
Mailing Address - Phone:815-468-7117
Mailing Address - Fax:815-468-7510
Practice Address - Street 1:2825 WEST DIVISION STREET
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950
Practice Address - Country:US
Practice Address - Phone:815-468-7117
Practice Address - Fax:815-468-7510
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U78046Medicare UPIN