Provider Demographics
NPI:1184674152
Name:SMITH, J. KYLE (OD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:KYLE
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 1:450 N MCPHERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3314
Mailing Address - Country:US
Mailing Address - Phone:707-964-5927
Mailing Address - Fax:707-964-6533
Practice Address - Street 1:450 N MCPHERSON ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3314
Practice Address - Country:US
Practice Address - Phone:707-964-5927
Practice Address - Fax:707-964-6533
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11804152WC0802X, 152WL0500X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA410048777OtherRRMCARE
CARR3046OtherRR MEDICARE
CASD0118040Medicaid
CA5187135Medicaid
CASD0118040Medicaid
CA5187135Medicaid
CA4662730001Medicare NSC