Healthcare Provider Details

I. General information

NPI: 1679543821
Provider Name (Legal Business Name): JERRY LEE MARTIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W AVENUE K
LANCASTER CA
93534-6502
US

IV. Provider business mailing address

1745 W AVENUE K
LANCASTER CA
93534-6502
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-8437
  • Fax: 661-940-1959
Mailing address:
  • Phone: 661-942-8437
  • Fax: 661-940-1959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT6288TPL
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT6288TPL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: