Provider Demographics
NPI:1083743017
Name:MARTINDALE & MARTINDALE PA
Entity Type:Organization
Organization Name:MARTINDALE & MARTINDALE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINDALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-837-7186
Mailing Address - Street 1:201 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-2027
Practice Address - Country:US
Practice Address - Phone:662-837-7186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087830Medicaid
MS09011572Medicaid
T20852Medicare UPIN
C00869Medicare ID - Type Unspecified
MS00087830Medicaid