Provider Demographics
NPI:1386652907
Name:MARTIN, MICHELLE MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:12750 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6307
Mailing Address - Country:US
Mailing Address - Phone:763-553-1811
Mailing Address - Fax:763-553-0131
Practice Address - Street 1:12750 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6307
Practice Address - Country:US
Practice Address - Phone:763-553-1811
Practice Address - Fax:763-553-0131
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3053152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410002870Medicare PIN