Healthcare Provider Details

I. General information

NPI: 1881757912
Provider Name (Legal Business Name): MARTIN EYE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E DUPONT RD
FORT WAYNE IN
46825-1553
US

IV. Provider business mailing address

1015 E DUPONT RD
FORT WAYNE IN
46825-1553
US

V. Phone/Fax

Practice location:
  • Phone: 260-416-0800
  • Fax:
Mailing address:
  • Phone: 260-416-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: SCOTT MARTIN
Title or Position: OWNER
Credential:
Phone: 260-416-0800