Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 11015804A | IN |
N | 111NI0900X | Internist | 11015804A | IN |
N | 207R00000X | Internist | 125056433 | IL |
N | 111NI0900X | Internist | 125056433 | IL |
Y | 207RG0100X | Gastroenterologist | 036139158 | IL |
NPI | 1003124280 |
---|---|
Provider Name | Melissa Andrea Martinez Mateo |
First Address | Carbondale, IL 62902-3988 |
Second Address | Carbondale, IL 62901-1031 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2010 |
Last Update Date | 25/08/2021 |