Provider Demographics
NPI:1508893348
Name:MARTIN, KELLY A (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:SANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:600 E VETERANS DR STE A
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4038
Mailing Address - Country:US
Mailing Address - Phone:931-372-1994
Mailing Address - Fax:931-684-8562
Practice Address - Street 1:600 E VETERANS DR STE A
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4038
Practice Address - Country:US
Practice Address - Phone:931-372-1994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNV02065Medicare UPIN