Provider Demographics
NPI:1619545852
Name:MARTINEZ, ALEXIS (DPM)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:314 MARCLARE ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1145
Mailing Address - Country:US
Mailing Address - Phone:918-533-8272
Mailing Address - Fax:
Practice Address - Street 1:215 E 1ST ST STE 310
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3190
Practice Address - Country:US
Practice Address - Phone:815-285-5801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016006000213ES0103X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program