Provider Demographics
NPI:1164536876
Name:VIVIEN M SMITH OD PSC
Entity Type:Organization
Organization Name:VIVIEN M SMITH OD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIEN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:859-224-8083
Mailing Address - Street 1:3735 PALOMAR CENTER DRIVE
Mailing Address - Street 2:SUITE 45
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1147
Mailing Address - Country:US
Mailing Address - Phone:859-224-8083
Mailing Address - Fax:859-223-2913
Practice Address - Street 1:3735 PALOMAR CENTER DRIVE
Practice Address - Street 2:SUITE 45
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1147
Practice Address - Country:US
Practice Address - Phone:859-224-8083
Practice Address - Fax:859-223-2913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1223DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012235Medicaid
KY77012235Medicaid
KY9307601Medicare PIN