Provider Demographics
NPI:1174684930
Name:SMITH, JERVY WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:JERVY
Middle Name:WILLIAM
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 1:6729 N PALM AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1076
Mailing Address - Country:US
Mailing Address - Phone:559-650-3937
Mailing Address - Fax:559-650-3927
Practice Address - Street 1:6729 N PALM AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-1076
Practice Address - Country:US
Practice Address - Phone:559-650-3937
Practice Address - Fax:559-650-3927
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT4957T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0049570Medicaid
CAT09830Medicare UPIN
CASD0049570Medicare PIN
CA0352710001Medicare NSC