Provider Demographics
NPI:1194565473
Name:MARTIN, MACKENZIE N (OD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:N
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MACKENZIE
Other - Middle Name:N
Other - Last Name:PULVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8890 E 116TH ST STE 190
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2857
Mailing Address - Country:US
Mailing Address - Phone:317-913-0700
Mailing Address - Fax:
Practice Address - Street 1:8890 E 116TH ST STE 190
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2857
Practice Address - Country:US
Practice Address - Phone:317-913-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-25
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004491A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist