Provider Demographics
NPI:1952393035
Name:MARTIN, NATHANIEL ALEXANDER IV (OD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:ALEXANDER
Last Name:MARTIN
Suffix:IV
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 1:405 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6119
Mailing Address - Country:US
Mailing Address - Phone:919-776-1012
Mailing Address - Fax:919-775-3420
Practice Address - Street 1:405 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-6119
Practice Address - Country:US
Practice Address - Phone:919-776-1012
Practice Address - Fax:919-775-3420
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1737152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018AKOtherBCBS
NC2471813DMedicare PIN
NC018AKOtherBCBS
NC2471361DMedicare PIN