Provider Demographics
NPI:1457809188
Name:MARTINEZ, JEREMIAS
Entity Type:Individual
Prefix:
First Name:JEREMIAS
Middle Name:
Last Name:MARTINEZ
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 1:1212 S 58TH CT
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-1116
Mailing Address - Country:US
Mailing Address - Phone:708-646-8684
Mailing Address - Fax:
Practice Address - Street 1:1212 S 58TH CT
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1116
Practice Address - Country:US
Practice Address - Phone:708-646-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM635-4349-12622255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer