Healthcare Provider Details

I. General information

NPI: 1205947736
Provider Name (Legal Business Name): ELIZABETH ANNE MARTIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 INTERSTATE PARKWAY
AUGUSTA GA
30909
US

IV. Provider business mailing address

1330 INTERSTATE PARKWAY
AUGUSTA GA
30909
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-2020
  • Fax: 706-855-6674
Mailing address:
  • Phone: 706-651-2020
  • Fax: 706-855-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMN 3191
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMA4591
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002811
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: