Provider Demographics
NPI:1245236496
Name:MARTIN, FREDERICK WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WARREN
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:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:KY
Mailing Address - Zip Code:42533-0306
Mailing Address - Country:US
Mailing Address - Phone:606-492-2211
Mailing Address - Fax:606-676-0873
Practice Address - Street 1:467 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2709
Practice Address - Country:US
Practice Address - Phone:423-784-2020
Practice Address - Fax:423-784-4940
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD3266152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1760573497Medicaid
01257740OtherAMERIGROUP
KY4619OtherAVESIS/MEDICAID
KY77008167Medicaid
000624846OtherHUMANA
49606OtherBCBSTN/BLUECARE/TENNCARE
KY406171015OtherRAILROAD MEDICARE
TN4599125Medicaid
000624846OtherHUMANA
KY1760573497Medicaid
KY0241610Medicare PIN
0487990006Medicare NSC
KYT53937Medicare UPIN