Provider Demographics
NPI:1457417586
Name:MARTELLARO, ROBERT LYNN (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYNN
Last Name:MARTELLARO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 N 93RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1705
Mailing Address - Country:US
Mailing Address - Phone:414-476-0113
Mailing Address - Fax:
Practice Address - Street 1:9211 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4516
Practice Address - Country:US
Practice Address - Phone:414-771-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5341820001Medicare ID - Type Unspecified