Provider Demographics
NPI:1831232503
Name:MARTIN, WILLIAM GREGORY (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GREGORY
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:PO BOX 3086
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-3086
Mailing Address - Country:US
Mailing Address - Phone:270-442-5342
Mailing Address - Fax:
Practice Address - Street 1:3220 IRVIN COBB DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-0337
Practice Address - Country:US
Practice Address - Phone:270-442-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1219 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012193Medicaid
KY77012193Medicaid
KY1676701Medicare ID - Type Unspecified