Provider Demographics
NPI:1114983897
Name:SMART, JIMMY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:D
Last Name:SMART
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 1:315 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-5403
Mailing Address - Country:US
Mailing Address - Phone:580-335-2020
Mailing Address - Fax:580-335-7008
Practice Address - Street 1:315 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-5403
Practice Address - Country:US
Practice Address - Phone:580-335-2020
Practice Address - Fax:580-335-7008
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200070610AMedicaid
U33944Medicare UPIN
243603101Medicare ID - Type Unspecified
OK200070610AMedicaid