Provider Demographics
NPI:1902913577
Name:KITAGAWA, MARTIN A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:KITAGAWA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 DEPTFORD CENTER RD
Mailing Address - Street 2:STE A
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5283
Mailing Address - Country:US
Mailing Address - Phone:856-848-3162
Mailing Address - Fax:856-848-5657
Practice Address - Street 1:1750 DEPTFORD CENTER RD
Practice Address - Street 2:STE A
Practice Address - City:DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-5283
Practice Address - Country:US
Practice Address - Phone:856-848-3162
Practice Address - Fax:856-848-5657
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA 00436200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
085723QB4Medicare ID - Type Unspecified
U30253Medicare UPIN