Provider Demographics
NPI:1619962727
Name:MARTIN, JOHN BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRUCE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 MICHIGAN AVE
Mailing Address - Street 2:5B
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2591
Mailing Address - Country:US
Mailing Address - Phone:847-869-1392
Mailing Address - Fax:847-869-1392
Practice Address - Street 1:838 MICHIGAN AVE
Practice Address - Street 2:5B
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2591
Practice Address - Country:US
Practice Address - Phone:847-869-1392
Practice Address - Fax:847-869-1392
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL381821Medicare ID - Type Unspecified