Provider Demographics
NPI:1881634228
Name:REPETTO, MARTIN J (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:REPETTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-784-2579
Mailing Address - Fax:
Practice Address - Street 1:1504 PATTON DR
Practice Address - Street 2:
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8144
Practice Address - Country:US
Practice Address - Phone:217-586-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME850732084P0800X
IL0361188642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270255000Medicaid
FL48048Medicare ID - Type Unspecified