Provider Demographics
NPI:1043412216
Name:TRUMBULL OPTICAL ASSC. INC
Entity Type:Organization
Organization Name:TRUMBULL OPTICAL ASSC. INC
Other - Org Name:MARTIN G. ELLIS O.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-638-4097
Mailing Address - Street 1:3018 STATE ROUTE 5 STE C
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9236
Mailing Address - Country:US
Mailing Address - Phone:330-638-4097
Mailing Address - Fax:330-637-0140
Practice Address - Street 1:3018 STATE ROUTE 5 STE C
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9236
Practice Address - Country:US
Practice Address - Phone:330-638-4097
Practice Address - Fax:330-637-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0907700Medicaid
OH0764300001Medicare NSC
OHT47044Medicare UPIN
OH9257821Medicare PIN