Provider Demographics
NPI:1780732123
Name:MARTIN, SERGE BARRY (OD)
Entity type:Individual
Prefix:DR
First Name:SERGE
Middle Name:BARRY
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 1:2361 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-5108
Mailing Address - Country:US
Mailing Address - Phone:615-896-0082
Mailing Address - Fax:
Practice Address - Street 1:2361 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-5108
Practice Address - Country:US
Practice Address - Phone:615-896-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD880152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61294Medicare UPIN
TN5413180001Medicare NSC