Provider Demographics
NPI:1760458269
Name:MARTIN, RICHARD ARTHUR (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ARTHUR
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 1:4626 SHASTA DAM BLVD
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9414
Mailing Address - Country:US
Mailing Address - Phone:530-275-0866
Mailing Address - Fax:530-275-8551
Practice Address - Street 1:4626 SHASTA DAM BLVD
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9414
Practice Address - Country:US
Practice Address - Phone:530-275-0866
Practice Address - Fax:530-275-8551
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8799T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU69975Medicare UPIN
CASD0087991Medicare UPIN
CASD0087991Medicare ID - Type Unspecified