Provider Demographics
NPI:1215516646
Name:MARTIN, RICHARD DANE (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DANE
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 1:305 ELAINES CT
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-2103
Mailing Address - Country:US
Mailing Address - Phone:608-930-4362
Mailing Address - Fax:608-930-4366
Practice Address - Street 1:305 ELAINES CT
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-2103
Practice Address - Country:US
Practice Address - Phone:608-930-4362
Practice Address - Fax:608-930-4366
Is Sole Proprietor?:No
Enumeration Date:2021-04-04
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI3680-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215516646Medicaid