Basic Information
| Provider Information | |||||||||
| NPI: | 1285632786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038476780 | ||||||||
| FaxNumber: | 5712238899 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 N NOLAN RIVER RD | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760337001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176452411 | ||||||||
| FaxNumber: | 8176453447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1957TG | TX | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1957 | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1272262-02 | 05 | TX | MEDICAID | 80181Q | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 11875 | 01 | TX | OPTICARE | OTHER |