Provider Demographics
NPI:1982165304
Name:MARTINCIC, DENISE MARIE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:MARTINCIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 N OCTAVIA AVE # 3
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-2624
Mailing Address - Country:US
Mailing Address - Phone:216-331-9365
Mailing Address - Fax:216-671-3991
Practice Address - Street 1:8259 N OCTAVIA AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-2624
Practice Address - Country:US
Practice Address - Phone:216-331-9365
Practice Address - Fax:216-671-3991
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
347B00000X, 347E00000X, 172A00000X
IL347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No347B00000XTransportation ServicesBus
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9987Medicaid