Provider Demographics
NPI:1922888486
Name:MARTIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 W WINDING TRL UNIT 202
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-5210
Mailing Address - Country:US
Mailing Address - Phone:312-342-5059
Mailing Address - Fax:
Practice Address - Street 1:6100 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2105
Practice Address - Country:US
Practice Address - Phone:314-342-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027848225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist