Provider Demographics
NPI:1295734952
Name:MARTIN, JOHN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4318 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1436
Mailing Address - Country:US
Mailing Address - Phone:708-508-2038
Mailing Address - Fax:708-246-4457
Practice Address - Street 1:4318 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1436
Practice Address - Country:US
Practice Address - Phone:708-508-2038
Practice Address - Fax:708-246-4457
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-040469207RP1001X
MI4301046776207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease