Provider Demographics
NPI:1831399559
Name:MARTIN, BRUCE W (OD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
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 1:49 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:CADIZ
Mailing Address - State:KY
Mailing Address - Zip Code:42211-9474
Mailing Address - Country:US
Mailing Address - Phone:270-924-9429
Mailing Address - Fax:270-924-9429
Practice Address - Street 1:49 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9474
Practice Address - Country:US
Practice Address - Phone:270-924-9429
Practice Address - Fax:270-924-9429
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1611DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9374401Medicare PIN
KYU26106Medicare UPIN