Provider Demographics
NPI:1053644666
Name:BLANC, SMITH (OD)
Entity Type:Individual
Prefix:DR
First Name:SMITH
Middle Name:
Last Name:BLANC
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 1:10860 NW 37TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-2701
Mailing Address - Country:US
Mailing Address - Phone:786-897-9472
Mailing Address - Fax:
Practice Address - Street 1:18610 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2406
Practice Address - Country:US
Practice Address - Phone:305-474-0463
Practice Address - Fax:305-474-8071
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4425152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001597300Medicaid