Provider Demographics
NPI:1063409142
Name:MARTIN, MATTHEW JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:MARTIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MI
Mailing Address - Zip Code:48611-9406
Mailing Address - Country:US
Mailing Address - Phone:989-662-2501
Mailing Address - Fax:989-662-6961
Practice Address - Street 1:955 W MIDLAND RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MI
Practice Address - Zip Code:48611-9406
Practice Address - Country:US
Practice Address - Phone:989-662-2501
Practice Address - Fax:989-662-6961
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004017152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Z96514OtherBCBS
MI0Z96514OtherBCBS
U77465Medicare UPIN
0N13160Medicare ID - Type Unspecified