Provider Demographics
NPI:1720061179
Name:MARTIN, ANDREW D (DPM)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:4650 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-424-3201
Practice Address - Fax:708-424-5001
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005084213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-005084Medicaid
IL480034880OtherRR MEDICARE
IL7416406OtherAETNA
IL016-005084Medicaid
IL3991860002Medicare NSC
IL3991860004Medicare NSC
IL480034880OtherRR MEDICARE
L95514Medicare ID - Type Unspecified