Provider Demographics
NPI:1336242254
Name:MARTIN, KRISTA M (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:M
Last Name:MARTIN
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 1:1245 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SN LUIS OBISP
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3907
Mailing Address - Country:US
Mailing Address - Phone:805-542-0700
Mailing Address - Fax:
Practice Address - Street 1:1550 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4819
Practice Address - Country:US
Practice Address - Phone:805-354-6038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004067152W00000X
CA12612152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist