Provider Demographics
NPI:1881618445
Name:MARTIN, CHRISTOPHER DALE II (OD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DALE
Last Name:MARTIN
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3738
Mailing Address - Country:US
Mailing Address - Phone:312-225-6200
Mailing Address - Fax:312-949-7389
Practice Address - Street 1:3948 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3738
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7389
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720039OtherMEDICARE PTAN
IL046009427Medicaid
IL502720039OtherMEDICARE PTAN