Provider Demographics
NPI:1265646848
Name:MARTIN, COLLEEN L (OD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 MONTROSE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1670
Mailing Address - Country:US
Mailing Address - Phone:818-249-1152
Mailing Address - Fax:818-249-9615
Practice Address - Street 1:2021 MONTROSE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1670
Practice Address - Country:US
Practice Address - Phone:818-249-1152
Practice Address - Fax:818-249-9615
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9043T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT95791Medicare UPIN