Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 18002594B | IN |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 18002594B | IN |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | 18002594B | IN |
N | 152WX0102X | Occupational Vision | 18002594B | IN |
NPI | 1356350474 |
---|---|
Provider Name | Dr. Scott E Martin |
First Address | Fort Wayne, IN 46825-1553 |
Second Address | Fort Wayne, IN 46825-1553 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000089436 | ANTHEM (01) | IN |
0786400001 | DMERC (01) | IN |
U33891 | (02) | IN |