Healthcare Provider Details

I. General information

NPI: 1881634228
Provider Name (Legal Business Name): MARTIN J REPETTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/05/2024
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 PATTON DR
MAHOMET IL
61853-8144
US

IV. Provider business mailing address

1120 N MELVIN ST
GIBSON CITY IL
60936-1477
US

V. Phone/Fax

Practice location:
  • Phone: 217-586-2633
  • Fax:
Mailing address:
  • Phone: 217-784-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME85073
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036118864
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: