Provider Demographics
NPI:1457583239
Name:MARTIN, LISA WOOTEN (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:WOOTEN
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 1:603 WHEAT AVE
Mailing Address - Street 2:SUITE 650
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4360
Mailing Address - Country:US
Mailing Address - Phone:229-243-8597
Mailing Address - Fax:229-243-1506
Practice Address - Street 1:603 WHEAT AVE
Practice Address - Street 2:SUITE 650
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4360
Practice Address - Country:US
Practice Address - Phone:229-243-8597
Practice Address - Fax:229-243-1506
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOPT002548OtherMEDICAL LICENSE
GA003104546AMedicaid