Provider Demographics
NPI:1356437065
Name:MARTIN, PATRICK J
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 S SUTTON LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-9467
Mailing Address - Country:US
Mailing Address - Phone:952-492-3915
Mailing Address - Fax:952-435-1624
Practice Address - Street 1:PEARLE VISION
Practice Address - Street 2:1056 BURNSVILLE CENTER
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306
Practice Address - Country:US
Practice Address - Phone:952-435-8821
Practice Address - Fax:952-435-1624
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C309MAOtherBLUE CROSS BLUE SHIELD
MN549023500Medicaid
MN911361OtherEYE MED / COLE VISION
MN3C309MAOtherBLUE CROSS BLUE SHIELD
MNT93181Medicare UPIN
MN410000975Medicare ID - Type UnspecifiedMEDICARE