Healthcare Provider Details

I. General information

NPI: 1245556695
Provider Name (Legal Business Name): GABRIEL J MARTINEZ-DIAZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 07/21/2022
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W. ADAMS ST. L L # 1
CHICAGO IL
60607
US

IV. Provider business mailing address

1021 W ADAMS ST STE LL
CHICAGO IL
60607-2934
US

V. Phone/Fax

Practice location:
  • Phone: 312-579-0700
  • Fax: 312-579-0701
Mailing address:
  • Phone: 312-579-0700
  • Fax: 312-579-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036138747
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036138747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: