Provider Demographics
NPI:1992867725
Name:MARTELLO, DESMOND J (DC)
Entity Type:Individual
Prefix:DR
First Name:DESMOND
Middle Name:J
Last Name:MARTELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10644 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5268
Mailing Address - Country:US
Mailing Address - Phone:708-425-2700
Mailing Address - Fax:
Practice Address - Street 1:10644 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5268
Practice Address - Country:US
Practice Address - Phone:708-425-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006379111N00000X, 111NN1001X, 111NR0400X, 111NS0005X, 111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1682339Medicare UPIN
IL709770Medicare ID - Type Unspecified