Provider Demographics
NPI:1356367429
Name:MARCIN, JUDITH LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:LYNN
Last Name:MARCIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LYNN
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:STE 406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:312-491-5020
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:STE 406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:312-633-5841
Practice Address - Fax:312-491-5020
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108355Medicaid
IL036108355Medicaid
ILL97852Medicare ID - Type Unspecified