Healthcare Provider Details

I. General information

NPI: 1376299040
Provider Name (Legal Business Name): ELIZA MARGUERITE WHATLEY MARTIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 12/27/2025
Certification Date: 12/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST STE B2
DRIGGS ID
83422-5034
US

IV. Provider business mailing address

7973 SPOON CREEK DR
VICTOR ID
83455-4992
US

V. Phone/Fax

Practice location:
  • Phone: 208-471-8721
  • Fax: 208-471-8727
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100599
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG004119
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003187
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4280
License Number StateMT
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number447T
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPOP280
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12793207-9934
License Number StateUT
# 8
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61409137
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: