Provider Demographics
NPI:1225057979
Name:MARTIN, SAMUEL A JR (OD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:MARTIN
Suffix:JR
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0308
Mailing Address - Country:US
Mailing Address - Phone:434-392-8355
Mailing Address - Fax:434-392-3042
Practice Address - Street 1:201 A ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1613
Practice Address - Country:US
Practice Address - Phone:434-392-8355
Practice Address - Fax:434-392-3042
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009203095Medicaid
VA540001094OtherRR MEDICARE
VA6271OtherDAVIS VISION
VA075554OtherBCBS
VA0225110001OtherDME MEDICARE
VA0225110001OtherDME MEDICARE
VA580930339Medicare ID - Type Unspecified