Provider Demographics
NPI:1780685719
Name:MARTIN, MICHAEL G (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
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 1:513 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-1749
Mailing Address - Country:US
Mailing Address - Phone:319-472-4741
Mailing Address - Fax:319-472-2827
Practice Address - Street 1:513 1ST AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-1749
Practice Address - Country:US
Practice Address - Phone:319-472-4741
Practice Address - Fax:319-472-2827
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2017-11-13
Deactivation Date:2017-11-02
Deactivation Code:
Reactivation Date:2017-11-13
Provider Licenses
StateLicense IDTaxonomies
IA01848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0245167Medicaid
IA0245167Medicaid
IAT01391Medicare UPIN
IA0439810001Medicare NSC