Provider Demographics
NPI:1588610372
Name:JENSEN, MARTIN J (OD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:JENSEN
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 1:105 ROBINS WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1820
Mailing Address - Country:US
Mailing Address - Phone:270-726-2022
Mailing Address - Fax:270-726-2035
Practice Address - Street 1:105 ROBINS WAY
Practice Address - Street 2:SUITE 206
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1820
Practice Address - Country:US
Practice Address - Phone:270-726-2022
Practice Address - Fax:270-726-2035
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1350DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77001352Medicaid
KYU68237Medicare UPIN
KY9367301Medicare PIN