Provider Demographics
NPI:1942309380
Name:MAIETTA, MARTHA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:MAIETTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 VINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1431
Mailing Address - Country:US
Mailing Address - Phone:860-229-1905
Mailing Address - Fax:860-826-7292
Practice Address - Street 1:14 VINE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1431
Practice Address - Country:US
Practice Address - Phone:860-229-1905
Practice Address - Fax:860-826-7292
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02123152W00000X
CT002123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004112306Medicaid
CT004112306Medicaid
CT410000425Medicare PIN