Provider Demographics
NPI:1376299040
Name:WHATLEY MARTIN, ELIZA MARGUERITE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZA
Middle Name:MARGUERITE
Last Name:WHATLEY MARTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7973 SPOON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-4992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 S KING ST # 103
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8551
Practice Address - Country:US
Practice Address - Phone:307-733-1441
Practice Address - Fax:307-734-8232
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12793207-9934152W00000X
MT4280152W00000X
PAOEG004119152W00000X
VA0618003187152W00000X
IDODP-100599152W00000X
WAOD61409137152W00000X
WY447T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist