Provider Demographics
NPI:1679543821
Name:MARTIN, JERRY LEE (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:MARTIN
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 1:1745 W AVENUE K
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6502
Mailing Address - Country:US
Mailing Address - Phone:661-942-8437
Mailing Address - Fax:661-940-1959
Practice Address - Street 1:1745 W AVENUE K
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6502
Practice Address - Country:US
Practice Address - Phone:661-942-8437
Practice Address - Fax:661-940-1959
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6288TPL152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6169OtherMESC PROVIDER NUMBER
CAZZ40293ZOtherB/C B/S GROUP IDENTIFIER
CA2673OtherDAVIS VISION PROVIDER NUM
CA410016191OtherRAILROAD MEDICARE NUMBER
CASD0062880OtherB/C B/S IDENTIFIER
CA410016191OtherRAILROAD MEDICARE NUMBER
CASD0062880OtherB/C B/S IDENTIFIER
CA410016191OtherRAILROAD MEDICARE NUMBER
CA6169OtherMESC PROVIDER NUMBER