Provider Demographics
NPI:1972519486
Name:MARTIN, PAUL T JR (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1836
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:4650 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1836
Practice Address - Country:US
Practice Address - Phone:708-424-3201
Practice Address - Fax:708-424-5001
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004378213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004378Medicaid
IL016004378Medicaid
IL4334360001Medicare NSC