Provider Demographics
NPI:1740015460
Name:MARTIN, KATHLEEN (ABOC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7629 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7419
Mailing Address - Country:US
Mailing Address - Phone:323-401-0661
Mailing Address - Fax:
Practice Address - Street 1:7629 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-7419
Practice Address - Country:US
Practice Address - Phone:323-401-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA216205156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician