Provider Demographics
NPI:1588615736
Name:MARTIN, MITCHELL L (OD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:L
Last Name:MARTIN
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 1:3080 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1449
Mailing Address - Country:US
Mailing Address - Phone:530-222-3166
Mailing Address - Fax:530-222-6539
Practice Address - Street 1:3080 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1449
Practice Address - Country:US
Practice Address - Phone:530-222-3166
Practice Address - Fax:530-222-6539
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13870T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP904ZOtherINDIVIDUAL MEDICARE PTAN
CACA408836OtherGROUP MEDICARE PTAN