Provider Demographics
NPI:1215155601
Name:MARTIN, MOLLY A (MD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:MC 856
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-2363
Mailing Address - Fax:
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-996-7414
Practice Address - Fax:312-413-8778
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-106034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics