Provider Demographics
NPI:1093853160
Name:MARTELL, JOHN GERARD (OPTOMETRIST)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GERARD
Last Name:MARTELL
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 DORSET ST
Mailing Address - Street 2:UNIVERSITY MALL
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6346
Mailing Address - Country:US
Mailing Address - Phone:802-863-3062
Mailing Address - Fax:802-863-6100
Practice Address - Street 1:155 DORSET ST
Practice Address - Street 2:UNIVERSITY MALL
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6346
Practice Address - Country:US
Practice Address - Phone:802-863-3062
Practice Address - Fax:802-863-6100
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT03000259152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTYO9451Medicare UPIN
VTJOVN3397Medicare ID - Type UnspecifiedGROUP