Provider Demographics
NPI:1427756212
Name:NWIADO, MARTIN B
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:B
Last Name:NWIADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6968 N WOLCOTT AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-7028
Mailing Address - Country:US
Mailing Address - Phone:773-943-0058
Mailing Address - Fax:
Practice Address - Street 1:6968 N WOLCOTT AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-7028
Practice Address - Country:US
Practice Address - Phone:773-943-0058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)