Healthcare Provider Details

I. General information

NPI: 1275761603
Provider Name (Legal Business Name): MATTHEW L MARTENS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 203RD ST STE 201
OLYMPIA FIELDS IL
60461-1182
US

IV. Provider business mailing address

360 W ILLINOIS ST APT 501
CHICAGO IL
60654-5280
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2120
  • Fax: 708-503-3230
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A10803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: