Provider Demographics
NPI:1164585758
Name:FREDERICK EYE CARE PLLC
Entity Type:Organization
Organization Name:FREDERICK EYE CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-335-2020
Mailing Address - Street 1:104 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-5436
Mailing Address - Country:US
Mailing Address - Phone:580-335-2020
Mailing Address - Fax:580-335-7008
Practice Address - Street 1:104 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-5436
Practice Address - Country:US
Practice Address - Phone:580-335-2020
Practice Address - Fax:580-335-7008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522354Medicare PIN
OK6144580001Medicare NSC