1457586976 NPI number — MARTINEZ EYE ASSOCIATES LLC

Table of content: (NPI 1457586976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457586976 NPI number — MARTINEZ EYE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTINEZ EYE ASSOCIATES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARTINEZ EYE ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457586976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809-0079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-219-3207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3412 WRIGHTSBORO RD
Provider Second Line Business Practice Location Address:
SUITE 905
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-2500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-736-3937
Provider Business Practice Location Address Fax Number:
706-736-3938
Provider Enumeration Date:
05/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DARANIJOH
Authorized Official First Name:
ABDUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
812-219-3207

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 2274 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 572742278A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: D20038 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 154675884C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: D16356 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: D14893 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000367155B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 914781558B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: D15972 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000182861D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003242108A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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