Provider Demographics
NPI:1386708139
Name:TRIBBET, MARTHA R (OD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:R
Last Name:TRIBBET
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARTHA
Other - Middle Name:R
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:8030 MALL PKWY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2542
Mailing Address - Country:US
Mailing Address - Phone:770-482-4835
Mailing Address - Fax:770-484-7487
Practice Address - Street 1:8030 MALL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2542
Practice Address - Country:US
Practice Address - Phone:770-482-4835
Practice Address - Fax:770-484-7487
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU66426Medicare UPIN