Healthcare Provider Details

I. General information

NPI: 1760117170
Provider Name (Legal Business Name): MAGGIE MARTIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAGGIE BRICELAND

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N FAIRFIELD DR
PENSACOLA FL
32506-4313
US

IV. Provider business mailing address

1531 CADENCE LOOP
CANTONMENT FL
32533-4736
US

V. Phone/Fax

Practice location:
  • Phone: 850-456-5059
  • Fax: 850-456-0461
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6412
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA2894
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: