Provider Demographics
NPI:1487664249
Name:MARTIN, BRAD D (OD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:D
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 1:1015 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1553
Mailing Address - Country:US
Mailing Address - Phone:260-416-0800
Mailing Address - Fax:260-416-0999
Practice Address - Street 1:1015 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1553
Practice Address - Country:US
Practice Address - Phone:260-416-0800
Practice Address - Fax:260-416-0999
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002830B152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000089437OtherANTHEM
IN0786400001OtherDMERC
IN0786400001OtherDMERC
IN000000089437OtherANTHEM