Provider Demographics
NPI:1619087939
Name:MARTIN, ROBERT EDWARD
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1866
Mailing Address - Country:US
Mailing Address - Phone:479-442-8961
Mailing Address - Fax:479-442-6440
Practice Address - Street 1:834 W NORTH ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-1866
Practice Address - Country:US
Practice Address - Phone:479-442-8961
Practice Address - Fax:479-442-6440
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART20185Medicare UPIN
AR0195930001Medicare NSC
AR48233Medicare ID - Type Unspecified