Healthcare Provider Details

I. General information

NPI: 1679673495
Provider Name (Legal Business Name): MARTINSVILLE VISION CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E WASHINGTON ST
MARTINSVILLE IN
46151-1554
US

IV. Provider business mailing address

219 E WASHINGTON ST
MARTINSVILLE IN
46151-1554
US

V. Phone/Fax

Practice location:
  • Phone: 765-342-6654
  • Fax: 765-342-0418
Mailing address:
  • Phone: 765-342-6654
  • Fax: 765-342-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001572B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003161B
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002989B
License Number StateIN

VIII. Authorized Official

Name: DR. AARON B CUNNINGHAM
Title or Position: PRESIDENT/OWNER
Credential: OD
Phone: 765-342-6654