Provider Demographics
NPI:1760004071
Name:MARTIN, KYLE D (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:D
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 1:391 LINCOLN PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-1080
Mailing Address - Country:US
Mailing Address - Phone:740-342-1784
Mailing Address - Fax:740-342-1791
Practice Address - Street 1:391 LINCOLN PARK DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1080
Practice Address - Country:US
Practice Address - Phone:740-342-1784
Practice Address - Fax:740-342-1791
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6847152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452164Medicaid