Basic Information
| Provider Information | |||||||||
| NPI: | 1114579992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 139 RITCHIE HWY STE B | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211461152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105447417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 139 RITCHIE HWY STE B | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211461152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105447417 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2019 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2693 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | TA2693 | 01 | MD | STATE LICENSE | OTHER |