Healthcare Provider Details

I. General information

NPI: 1184087462
Provider Name (Legal Business Name): MATTHEW MARTINI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 76TH ST STE 3880
PLEASANT PRAIRIE WI
53158-1984
US

IV. Provider business mailing address

6308 8TH AVE
KENOSHA WI
53143-5031
US

V. Phone/Fax

Practice location:
  • Phone: 626-563-6502
  • Fax:
Mailing address:
  • Phone: 262-577-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number69201
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number69201
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: