Healthcare Provider Details

I. General information

NPI: 1235382011
Provider Name (Legal Business Name): JAMES GORDON MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-0437
  • Fax: 708-783-6919
Mailing address:
  • Phone: 708-783-0437
  • Fax: 708-783-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036122080
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036122080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: