Provider Demographics
NPI:1629059662
Name:MENCHACA, MARTHA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:MENCHACA
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 1:611 W PARK
Mailing Address - Street 2:FAPC
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61802
Mailing Address - Country:US
Mailing Address - Phone:217-902-6954
Mailing Address - Fax:217-902-7711
Practice Address - Street 1:611 W PARK
Practice Address - Street 2:FAPC
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-902-6954
Practice Address - Fax:217-902-7711
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1119752085D0003X, 2085R0202X
MA2244442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging