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General NPI Number Information
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NPI Number | 1457583239
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Entity Type | Individual
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Provider Name | LISA WOOTEN MARTIN O.D.
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Gender | Female
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Dates
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Enumeration Date | 08/12/2009
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Last Update Date | 09/13/2017
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Provider Practice Location Address
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Address Line | 603 WHEAT AVE SUITE 650
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City | BAINBRIDGE
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State | GA
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Zip | 39819-4360
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Country | US
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Telephone | 229-243-8597
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Fax | 229-243-1506
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Provider Business Mailing Address
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Address Line | 603 WHEAT AVE SUITE 650
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City | BAINBRIDGE
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State | GA
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Zip | 39819-4360
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Country | US
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Telephone | 229-243-8597
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Fax | 229-243-1506
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT002548
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License Number State | GA
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