Provider Demographics
NPI:1023196276
Name:SMART, SAMUEL C (DOCTOR OF OPTOMETRY)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:C
Last Name:SMART
Suffix:
Gender:M
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 BUTLER ROAD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405
Mailing Address - Country:US
Mailing Address - Phone:540-373-3021
Mailing Address - Fax:540-373-5565
Practice Address - Street 1:230 BUTLER ROAD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405
Practice Address - Country:US
Practice Address - Phone:540-373-3021
Practice Address - Fax:540-373-5565
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015625OtherANTBCBS
VA015625OtherANTBCBS
VA410000656Medicare ID - Type Unspecified