Provider Demographics
NPI:1578655874
Name:MARTINSBURG OPTICAL INC
Entity Type:Organization
Organization Name:MARTINSBURG OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-3095
Mailing Address - Street 1:608 W ADDITION ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2614
Mailing Address - Country:US
Mailing Address - Phone:304-263-3095
Mailing Address - Fax:304-263-6339
Practice Address - Street 1:608 W ADDITION ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2614
Practice Address - Country:US
Practice Address - Phone:304-263-3095
Practice Address - Fax:304-263-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0151710000Medicaid
WV001709848OtherBLUECROSS BLUESHIELD
WV0151710000Medicaid