=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356437065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK J MARTIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 09/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PEARLE VISION 1056 BURNSVILLE CENTER
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-435-8821
-----------------------------------------------------
Fax | 952-435-1624
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 S SUTTON LAKE BLVD
-----------------------------------------------------
City | JORDAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55352-9467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-492-3915
-----------------------------------------------------
Fax | 952-435-1624
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2093
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------