Provider Demographics
NPI:1093877862
Name:SMITH, LISA GODWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:GODWIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5227 BUCKEYSTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7535
Mailing Address - Country:US
Mailing Address - Phone:301-846-4055
Mailing Address - Fax:301-846-4158
Practice Address - Street 1:5227 BUCKEYSTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7535
Practice Address - Country:US
Practice Address - Phone:301-846-4055
Practice Address - Fax:301-846-4158
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU86411Medicare UPIN