Provider Demographics
NPI:1356350474
Name:MARTIN, SCOTT E (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:E
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 1:1015 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1553
Mailing Address - Country:US
Mailing Address - Phone:260-416-0800
Mailing Address - Fax:260-416-0999
Practice Address - Street 1:1015 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1553
Practice Address - Country:US
Practice Address - Phone:260-416-0800
Practice Address - Fax:260-416-0999
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002594B152WX0102X, 152W00000X, 152WL0500X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0786400001OtherDMERC
IN000000089436OtherANTHEM
IN000000089436OtherANTHEM
INU33891Medicare UPIN