Provider Demographics
NPI:1003816943
Name:WHITE, MARTIN R (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:R
Last Name:WHITE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:6110 MAPLECREST RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2524
Mailing Address - Country:US
Mailing Address - Phone:260-486-8833
Mailing Address - Fax:260-486-8784
Practice Address - Street 1:6110 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2524
Practice Address - Country:US
Practice Address - Phone:260-486-8833
Practice Address - Fax:260-486-8784
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002542B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU33154Medicare UPIN
IN138850Medicare ID - Type Unspecified