Healthcare Provider Details

I. General information

NPI: 1255317533
Provider Name (Legal Business Name): MARTHA YANEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 S PULASKI RD
CHICAGO IL
60629-4400
US

IV. Provider business mailing address

2525 S MICHIGAN AVE MEDICAL STAFF OFFICE
CHICAGO IL
60616-2477
US

V. Phone/Fax

Practice location:
  • Phone: 312-567-7500
  • Fax: 312-447-7740
Mailing address:
  • Phone: 312-567-5677
  • Fax: 312-567-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036088167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: