Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | IL |
NPI | 1033110366 |
---|---|
Provider Name | Dr. Nicolas C Martinez |
First Address | Elmhurst, IL 60126-2122 |
Second Address | Chicago, IL 60623-3824 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
162248 | BLUE CROSS BLUE SHIELD (01) | IL |
K1631 | (02) | IL |