Healthcare Provider Details

I. General information

NPI: 1003124280
Provider Name (Legal Business Name): MELISSA A MARTINEZ MATEO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA MARTINEZ VISALLI

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 W MAIN ST
CARBONDALE IL
62901-1031
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-5361
  • Fax: 618-351-4878
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125056433
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11015804A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01072250A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036139158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: