Provider Demographics
NPI:1558300210
Name:MARTINI, WISAM (MD)
Entity Type:Individual
Prefix:
First Name:WISAM
Middle Name:
Last Name:MARTINI
Suffix:
Gender:M
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2150 GETTLER ST STE 400
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2385
Practice Address - Country:US
Practice Address - Phone:219-865-0893
Practice Address - Fax:219-865-3599
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073342207RI0011X, 207RC0000X
OH35092774207RI0011X
IN01087451A207RI0011X, 207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2928827Medicaid
MI0501917OtherBCBS PIN NUMBER
MI156505OtherGREAT LAKES HEALTH PLAN PROVIDER NUMBER
MI7933806OtherAETNA PROVIDER NUMBER
OH2928827Medicaid
MIH55011Medicare UPIN
OHH140800Medicare PIN