Provider Demographics
NPI:1235148875
Name:SMITH, CHARLES M III (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:SMITH
Suffix:III
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:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-0969
Mailing Address - Country:US
Mailing Address - Phone:706-278-6113
Mailing Address - Fax:706-226-5741
Practice Address - Street 1:415 W CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-4267
Practice Address - Country:US
Practice Address - Phone:706-278-6113
Practice Address - Fax:706-226-5741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000892152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU25273Medicare UPIN
GA41ZCBBLMedicare ID - Type UnspecifiedMEDICARE NUMBER
GA0157600002Medicare NSC