Provider Demographics
NPI:1043277791
Name:SMITH, JOHN O (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:SMITH
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:PO BOX 654
Mailing Address - Street 2:
Mailing Address - City:HENNESSEY
Mailing Address - State:OK
Mailing Address - Zip Code:73742-0654
Mailing Address - Country:US
Mailing Address - Phone:405-853-6800
Mailing Address - Fax:405-853-6805
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HENNESSEY
Practice Address - State:OK
Practice Address - Zip Code:73742-1744
Practice Address - Country:US
Practice Address - Phone:405-853-6800
Practice Address - Fax:405-853-6805
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1014152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731129821001OtherBCBS PAYER ID
OKT40656Medicare UPIN
OK731129821001OtherBCBS PAYER ID