Provider Demographics
NPI:1093704264
Name:MARTIN, STANLEY MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:MICHAEL
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 1:1011 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1692
Mailing Address - Country:US
Mailing Address - Phone:209-575-2020
Mailing Address - Fax:209-758-5693
Practice Address - Street 1:1011 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1692
Practice Address - Country:US
Practice Address - Phone:209-575-2020
Practice Address - Fax:209-758-5693
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5180T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410043677OtherRAILROAD MEDICARE
CASD0051800Medicaid
CASD0051800Medicaid
410043677OtherRAILROAD MEDICARE