Provider Demographics
NPI:1164522264
Name:WYMAN, MARTY J (OD)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:J
Last Name:WYMAN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:625 BALTIMORE BLVD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6178
Practice Address - Country:US
Practice Address - Phone:410-848-5442
Practice Address - Fax:410-848-5578
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDTA808152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDXY26OtherBLUE CROSS BLUE SHIELD