Provider Demographics
NPI:1770536542
Name:MARTIN, JOSEPH HAROLD (OD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:HAROLD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19101 EAGLEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-3801
Mailing Address - Country:US
Mailing Address - Phone:612-558-6660
Mailing Address - Fax:
Practice Address - Street 1:7600 PARKLAWN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5125
Practice Address - Country:US
Practice Address - Phone:952-288-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410001025Medicare ID - Type Unspecified
T39820Medicare UPIN