Provider Demographics
NPI:1134112733
Name:MARTINO, RICHARD CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:MARTINO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:144 ANGELL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-2120
Mailing Address - Country:US
Mailing Address - Phone:774-261-8595
Mailing Address - Fax:774-261-8595
Practice Address - Street 1:144 ANGELL BROOK DR
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-2120
Practice Address - Country:US
Practice Address - Phone:774-261-8595
Practice Address - Fax:774-261-8595
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0328073Medicaid
148858Medicare PIN
MA0328073Medicaid