Provider Demographics
NPI:1427066232
Name:CHRIS MARTIN II OD PC
Entity type:Organization
Organization Name:CHRIS MARTIN II OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:815-929-0429
Mailing Address - Street 1:2080 N. STATE RT 20
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60915
Mailing Address - Country:US
Mailing Address - Phone:815-929-0429
Mailing Address - Fax:815-929-0530
Practice Address - Street 1:2080 N. STATE RT 50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-929-0429
Practice Address - Fax:815-929-0530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213946Medicare PIN
ILV07647Medicare UPIN