Provider Demographics
NPI:1629059662
Name:MENCHACA, MARTHA G (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:G
Last Name:MENCHACA
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 1:4130 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4312
Mailing Address - Country:US
Mailing Address - Phone:312-580-5755
Mailing Address - Fax:
Practice Address - Street 1:4130 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4312
Practice Address - Country:US
Practice Address - Phone:312-580-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1119752085R0202X, 2085D0003X
MA2244442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology