Provider Demographics
NPI:1407903172
Name:MARTIN, STANLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
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 1:11845 W WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5169
Mailing Address - Country:US
Mailing Address - Phone:623-362-2575
Mailing Address - Fax:
Practice Address - Street 1:10336 W COGGINS DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3438
Practice Address - Country:US
Practice Address - Phone:623-933-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ74185Medicare ID - Type Unspecified
AZT76837Medicare UPIN