Provider Demographics
NPI:1891006276
Name:VANSTRATEN, MARTA M (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:M
Last Name:VANSTRATEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARTA
Other - Middle Name:MANUELA
Other - Last Name:HUBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:403 E. 1ST STREET
Mailing Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-5580
Mailing Address - Fax:815-285-5584
Practice Address - Street 1:403 E. 1ST STREET
Practice Address - Street 2:KATHERINE SHAW BETHEA HOSPITAL
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5580
Practice Address - Fax:815-285-5584
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1006276207ZP0102X
MI5101018708208D00000X
IL036.143928207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036143928Medicaid
ILF400444560OtherMEDICARE PTAN