Provider Demographics
NPI:1518305440
Name:MARTIN, JACE DALE JR (OD)
Entity Type:Individual
Prefix:DR
First Name:JACE
Middle Name:DALE
Last Name:MARTIN
Suffix:JR
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 1:1644 STOKLEY LN
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-2356
Mailing Address - Country:US
Mailing Address - Phone:615-310-5481
Mailing Address - Fax:
Practice Address - Street 1:1644 STOKLEY LN
Practice Address - Street 2:
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-2356
Practice Address - Country:US
Practice Address - Phone:615-310-5481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I412119Medicare PIN