Provider Demographics
NPI:1023504818
Name:MARTIN, TRENT WAYNE (OD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:WAYNE
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 1:113 CORTEZ CV
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-8490
Mailing Address - Country:US
Mailing Address - Phone:731-610-0858
Mailing Address - Fax:
Practice Address - Street 1:1296 UNION UNIVERSITY DR STE B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3714
Practice Address - Country:US
Practice Address - Phone:731-513-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist