Provider Demographics
NPI:1518074392
Name:MARTIN, LARA J (OD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:J
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 1:139 SHELTON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-2555
Mailing Address - Country:US
Mailing Address - Phone:864-542-1308
Mailing Address - Fax:
Practice Address - Street 1:735 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1281
Practice Address - Country:US
Practice Address - Phone:864-542-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13714Medicaid
SCD13714Medicaid
SCAA10976738Medicare ID - Type Unspecified