Basic Information
| Provider Information | |||||||||
| NPI: | 1205947736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 INTERSTATE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066512020 | ||||||||
| FaxNumber: | 7068556674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 INTERSTATE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066512020 | ||||||||
| FaxNumber: | 7068556674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | MN 3191 | MN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | MA4591 | MA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPT002811 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 202I412570 | 01 | GA | MEDICARE PTAN | OTHER |