Provider Demographics
NPI:1245382266
Name:SMOKE, STEVEN ALAN (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:ALAN
Last Name:SMOKE
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 1:400 E FRONT ST
Mailing Address - Street 2:STE A
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1403
Mailing Address - Country:US
Mailing Address - Phone:269-695-3434
Mailing Address - Fax:269-695-2656
Practice Address - Street 1:400 E FRONT ST
Practice Address - Street 2:STE A
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1403
Practice Address - Country:US
Practice Address - Phone:269-695-3434
Practice Address - Fax:269-695-2656
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI04901003221152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI003743A3321OtherVSP PROVIDER NUMBER
MIP89185OtherBLUE CARE NETWORK
MIP00240130Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MIP18500001Medicare ID - Type UnspecifiedMEMBER NUMBER
MIU18865Medicare UPIN
MIP18480001Medicare ID - Type UnspecifiedMEMBER NUMBER
MI003743A3321OtherVSP PROVIDER NUMBER
MIP18510001Medicare ID - Type UnspecifiedMEMBER NUMBER