Provider Demographics
NPI:1205947736
Name:MARTIN, ELIZABETH ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 INTERSTATE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909
Mailing Address - Country:US
Mailing Address - Phone:706-651-2020
Mailing Address - Fax:706-855-6674
Practice Address - Street 1:1330 INTERSTATE PARKWAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-651-2020
Practice Address - Fax:706-855-6674
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 3191152W00000X
MAMA4591152W00000X
GAOPT002811152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I412570OtherMEDICARE PTAN