Basic Information
| Provider Information | |||||||||
| NPI: | 1861493330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DUSTAN | ||||||||
| MiddleName: | CHRIS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 S VAN BUREN RD | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272885324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366232020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001304 | VA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1895 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 093MO | 01 | NC | BCBS PROVIDER NUMBER | OTHER | 89093MO | 05 | NC | MEDICAID |