1093094690 NPI number — DR. ALMA MIA ROSAL MARTIJA MD

Table of content: DR. ALMA MIA ROSAL MARTIJA MD (NPI 1093094690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093094690 NPI number — DR. ALMA MIA ROSAL MARTIJA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIJA
Provider First Name:
ALMA MIA
Provider Middle Name:
ROSAL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WULFF
Provider Other First Name:
ALMA MIA
Provider Other Middle Name:
MARTIJA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1093094690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 COPPERFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
JOLIET
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60432-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-726-2368
Provider Business Mailing Address Fax Number:
815-774-4799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 COPPERFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60432-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-726-2368
Provider Business Practice Location Address Fax Number:
815-774-4799
Provider Enumeration Date:
08/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  036.103214 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036-103214 . This is a "DEPT OF FINANCIAL AND PROFESSIONAL REGULATION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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