Provider Demographics
NPI:1760502314
Name:MARTINEZ, ANTONIO (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:MARTINEZ
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 1:1438 W PRATT BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4216
Mailing Address - Country:US
Mailing Address - Phone:773-220-0909
Mailing Address - Fax:
Practice Address - Street 1:1438 W PRATT BLVD APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4216
Practice Address - Country:US
Practice Address - Phone:773-381-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.005960103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP29015Medicare UPIN