Provider Demographics
NPI:1073563573
Name:SMITH, CORY W (OD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:27 MONTEBELLO RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1236
Mailing Address - Country:US
Mailing Address - Phone:719-545-1530
Mailing Address - Fax:719-545-2899
Practice Address - Street 1:27 MONTEBELLO RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1236
Practice Address - Country:US
Practice Address - Phone:719-545-1530
Practice Address - Fax:719-545-2899
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO2379OtherEYEMED EYECARE
COP00041114OtherRAILROAD MEDICARE
CO920713020820OtherEYE SPECIALISTS
COSM66441OtherANTHEM BCBS
CO0452890001OtherMEDICARE DMERC
CO02628384Medicaid
CO608439600OtherUS DEPT LABOR WORK COMP
CO66441OtherANTHEM
COSM66441OtherANTHEM BCBS
CO66441OtherANTHEM