Provider Demographics
NPI:1689036923
Name:MARTINEZ-KNOUSE, PHILLIP DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DOUGLAS
Last Name:MARTINEZ-KNOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PHILLIP
Other - Middle Name:DOUGLAS
Other - Last Name:KNOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 735031
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5031
Mailing Address - Country:US
Mailing Address - Phone:262-434-8800
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.149823207RH0003X
WI22233-875207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100204204Medicaid