Provider Demographics
NPI:1861493330
Name:MARTIN, DUSTAN CHRIS (OD)
Entity Type:Individual
Prefix:DR
First Name:DUSTAN
Middle Name:CHRIS
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:812 S VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5324
Practice Address - Country:US
Practice Address - Phone:336-623-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001304152W00000X
NC1895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093MOOtherBCBS PROVIDER NUMBER
NC89093MOMedicaid
NC89093MOMedicaid
NC2472782AMedicare PIN
NC2472782Medicare PIN
NC2472782BMedicare PIN
NC2472782EMedicare PIN
NC2472782DMedicare PIN
NC2472782CMedicare PIN