Provider Demographics
NPI:1508531237
Name:MARTINEZ, MARIO ROMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ROMAN
Last Name:MARTINEZ
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 1:4 KINGDOM CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7600
Mailing Address - Country:US
Mailing Address - Phone:501-773-8038
Mailing Address - Fax:
Practice Address - Street 1:1270 ARBOR PLACE MALL
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7105
Practice Address - Country:US
Practice Address - Phone:770-942-9827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist