Provider Demographics
NPI:1003841420
Name:MARTIN, STANLEY R (OD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:R
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 1:231 NORTHGATE DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1426
Mailing Address - Country:US
Mailing Address - Phone:931-473-1986
Mailing Address - Fax:931-473-1334
Practice Address - Street 1:231 NORTHGATE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1426
Practice Address - Country:US
Practice Address - Phone:931-473-1986
Practice Address - Fax:931-473-1334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1185T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU12559Medicare UPIN
TN1253720001Medicare NSC
TN3597727Medicare PIN