Healthcare Provider Details

I. General information

NPI: 1386713196
Provider Name (Legal Business Name): GARY MARSHALL MART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 MONROE AVE
RIVER FOREST IL
60305-1426
US

IV. Provider business mailing address

7061 NORTH AVE # 506
OAK PARK IL
60302-1015
US

V. Phone/Fax

Practice location:
  • Phone: 312-509-3910
  • Fax: 312-277-6565
Mailing address:
  • Phone: 312-509-3910
  • Fax: 844-562-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036101590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: