1225057979 NPI number — SAMUEL A. MARTIN JR. O.D.

Table of content: CASSANDRA HEIKKINEN RN (NPI 1871474098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225057979 NPI number — SAMUEL A. MARTIN JR. O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
SAMUEL
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1225057979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23901-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-392-8355
Provider Business Mailing Address Fax Number:
434-392-3042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 A ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-392-8355
Provider Business Practice Location Address Fax Number:
434-392-3042
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000089 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009203095 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540001094 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 6271 . This is a "DAVIS VISION" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 075554 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0225110001 . This is a "DME MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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