Provider Demographics
NPI:1689734964
Name:MARTINO, MARY M (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:MARTINO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 KETTERING RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-5364
Mailing Address - Country:US
Mailing Address - Phone:847-226-0267
Mailing Address - Fax:
Practice Address - Street 1:1324 KETTERING RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-5364
Practice Address - Country:US
Practice Address - Phone:847-226-0267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004178213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL600-01724OtherBCBS OF ILLINOIS
IL600-01724OtherBCBS OF ILLINOIS
ILK44564Medicare PIN