Provider Demographics
NPI:1497891378
Name:MARTIN, WILLIAM R (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
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:KETTERING TOWER LOBBY
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45423
Mailing Address - Country:US
Mailing Address - Phone:937-228-8811
Mailing Address - Fax:937-228-2117
Practice Address - Street 1:KETTERING TOWER LOBBY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45423
Practice Address - Country:US
Practice Address - Phone:937-228-8811
Practice Address - Fax:937-228-2117
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3361152W00000X
OHT551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466850001OtherDEMERC
OHT78483Medicare UPIN
OH0450603Medicare ID - Type Unspecified
OH0466850001Medicare NSC