Healthcare Provider Details

I. General information

NPI: 1528221082
Provider Name (Legal Business Name): MISHA LEE TABER MARTINEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2008
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 MYRTLE AVE STE 2
GRANITE CITY IL
62040-5012
US

IV. Provider business mailing address

3165 MYRTLE AVE STE 2
GRANITE CITY IL
62040-5012
US

V. Phone/Fax

Practice location:
  • Phone: 618-876-7500
  • Fax: 618-876-0807
Mailing address:
  • Phone: 618-876-7500
  • Fax: 618-876-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-129509
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2011012182
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: