Provider Demographics
NPI:1861811192
Name:MARTIN, AMARILIS ANDREA (MD)
Entity type:Individual
Prefix:
First Name:AMARILIS
Middle Name:ANDREA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMARILIS
Other - Middle Name:ANDREA
Other - Last Name:CORNEJO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS ROAD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-9452
Practice Address - Country:US
Practice Address - Phone:631-444-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011059362080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine