Provider Demographics
NPI:1528221082
Name:MARTINEZ, MISHA LEE TABER (MD)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:LEE TABER
Last Name:MARTINEZ
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 1:3165 MYRTLE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5012
Mailing Address - Country:US
Mailing Address - Phone:618-876-7500
Mailing Address - Fax:618-876-0807
Practice Address - Street 1:3165 MYRTLE AVE STE 2
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-5012
Practice Address - Country:US
Practice Address - Phone:618-876-7500
Practice Address - Fax:618-876-0807
Is Sole Proprietor?:No
Enumeration Date:2008-07-04
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129509208000000X
MO2011012182208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics