Provider Demographics
NPI:1497101125
Name:MARTIN, VIRGINIA (OD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
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 1:2495 BEN IRVIN RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-9632
Mailing Address - Country:US
Mailing Address - Phone:502-275-1532
Mailing Address - Fax:
Practice Address - Street 1:111 FIELDSTONE DR STE 100
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-7108
Practice Address - Country:US
Practice Address - Phone:478-453-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2897152W00000X
GAOPT003002152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist