Provider Demographics
NPI:1649289265
Name:MARTHA ELLEN MYERS, O.D. PA
Entity type:Organization
Organization Name:MARTHA ELLEN MYERS, O.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-527-9790
Mailing Address - Street 1:2875 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7625
Mailing Address - Country:US
Mailing Address - Phone:479-527-9790
Mailing Address - Fax:479-527-9792
Practice Address - Street 1:2875 W 6TH ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7625
Practice Address - Country:US
Practice Address - Phone:479-527-9790
Practice Address - Fax:479-527-9792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154135722Medicaid
AR154135722Medicaid