Provider Demographics
NPI:1942234034
Name:KALISH, MARTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:KALISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:MARTIN
Other - Middle Name:
Other - Last Name:KALISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:12430 PEBBLE STONE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-6759
Mailing Address - Country:US
Mailing Address - Phone:239-482-2020
Mailing Address - Fax:239-482-2020
Practice Address - Street 1:12430 PEBBLE STONE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-6759
Practice Address - Country:US
Practice Address - Phone:239-482-2020
Practice Address - Fax:239-482-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA0000EG375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2227085000OtherIBX KEYSTONE HMO
2227085000OtherIBX KEYSTONE HMO