Provider Demographics
NPI:1669561478
Name:NELSON, MARTINE THERESE (MD)
Entity type:Individual
Prefix:
First Name:MARTINE
Middle Name:THERESE
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2745 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3280
Mailing Address - Country:US
Mailing Address - Phone:630-717-9600
Mailing Address - Fax:630-717-5297
Practice Address - Street 1:2745 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-3280
Practice Address - Country:US
Practice Address - Phone:630-717-9600
Practice Address - Fax:630-717-5297
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360674672080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601930OtherBLUE CROSS BLUE SHEILD
IL036067467Medicaid