Provider Demographics
NPI:1093776098
Name:SMITH, MARLA C (OD)
Entity Type:Individual
Prefix:DR
First Name:MARLA
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-2742
Mailing Address - Country:US
Mailing Address - Phone:417-886-3937
Mailing Address - Fax:417-886-1285
Practice Address - Street 1:1265 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4278
Practice Address - Country:US
Practice Address - Phone:417-886-3937
Practice Address - Fax:417-886-1285
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002006619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315803312Medicaid
MO315803304Medicaid