Provider Demographics
NPI:1003077199
Name:CHARLENE SMITH MD PA
Entity Type:Organization
Organization Name:CHARLENE SMITH MD PA
Other - Org Name:LIVINGSTON EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-327-3937
Mailing Address - Street 1:410 E CHURCH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-2966
Mailing Address - Country:US
Mailing Address - Phone:936-327-3937
Mailing Address - Fax:
Practice Address - Street 1:410 E CHURCH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-2966
Practice Address - Country:US
Practice Address - Phone:936-327-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3795207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192974701Medicaid
TX192974701Medicaid
1210730001Medicare NSC