Provider Demographics
NPI:1851384218
Name:HETLAND, MARTIN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LEE
Last Name:HETLAND
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 1:3855 BROAD ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7109
Mailing Address - Country:US
Mailing Address - Phone:805-545-8100
Mailing Address - Fax:805-548-8785
Practice Address - Street 1:3855 BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7109
Practice Address - Country:US
Practice Address - Phone:805-545-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9744T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V80451Medicare UPIN
1192710001Medicare ID - Type Unspecified
OP9744Medicare ID - Type Unspecified