Provider Demographics
NPI:1023002540
Name:SMICK, KIRK L (OD)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:L
Last Name:SMICK
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 1:1000 CORPORATE CENTER DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4180
Mailing Address - Country:US
Mailing Address - Phone:770-968-8888
Mailing Address - Fax:770-960-2473
Practice Address - Street 1:1000 CORPORATE CENTER DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4180
Practice Address - Country:US
Practice Address - Phone:770-968-8888
Practice Address - Fax:770-960-2473
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000737152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000004683DMedicaid
GA406540201OtherRAILROAD MEDICARE
GA000004683DMedicaid
T97840Medicare UPIN