Healthcare Provider Details

I. General information

NPI: 1316674419
Provider Name (Legal Business Name): MICHAL MARTIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5754 KYLE PKWY
KYLE TX
78640-2404
US

IV. Provider business mailing address

5754 KYLE PKWY
KYLE TX
78640-2404
US

V. Phone/Fax

Practice location:
  • Phone: 512-256-5315
  • Fax:
Mailing address:
  • Phone: 512-256-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10601
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: