Healthcare Provider Details

I. General information

NPI: 1508531237
Provider Name (Legal Business Name): MARIO ROMAN MARTINEZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 INMAN VILLAGE PKWY NE STE 3
ATLANTA GA
30307-5523
US

IV. Provider business mailing address

870 INMAN VILLAGE PKWY NE STE 3
ATLANTA GA
30307-5523
US

V. Phone/Fax

Practice location:
  • Phone: 404-589-0822
  • Fax: 404-589-4766
Mailing address:
  • Phone: 404-589-0822
  • Fax: 404-589-4766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003361
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: