Provider Demographics
NPI:1205850401
Name:SMITH, ELIZABETH BLADEK (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:BLADEK
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:850 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4238
Mailing Address - Country:US
Mailing Address - Phone:860-443-2414
Mailing Address - Fax:860-444-0371
Practice Address - Street 1:850 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4238
Practice Address - Country:US
Practice Address - Phone:860-443-2414
Practice Address - Fax:860-444-0371
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090002325CT03OtherANTHEM BLUE CROSS
CTCT2325OtherEYEMED VISION PLAN