Provider Demographics
NPI:1114929460
Name:SMITH, STEPHEN DAMON (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DAMON
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 1:140 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1332
Mailing Address - Country:US
Mailing Address - Phone:502-587-8696
Mailing Address - Fax:502-587-8165
Practice Address - Street 1:140 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1332
Practice Address - Country:US
Practice Address - Phone:502-587-8696
Practice Address - Fax:502-587-8165
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002709152W00000X
KY1445 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000198612OtherANTHEM PROVIDER
KY918468OtherBLOCK PROVIDER
KY1445DTOtherKY OPTOMETRY LICENSE
KY77340503Medicaid
IN18002709OtherIN OPTOMETRY LICENSE
KY21434OtherCVC PROVIDER
KY11221323OtherCAQH
KY11221323OtherCAQH
KY21434OtherCVC PROVIDER
KY1889601Medicare PIN