Provider Demographics
NPI:1285626143
Name:SMITH, GARY E (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
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 1:10725 SE 256TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-8285
Mailing Address - Country:US
Mailing Address - Phone:253-852-8880
Mailing Address - Fax:253-479-0104
Practice Address - Street 1:10725 SE 256TH ST
Practice Address - Street 2:STE 4
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-8285
Practice Address - Country:US
Practice Address - Phone:253-852-8880
Practice Address - Fax:253-479-0104
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASM0620OtherBCBS
WA2104909Medicaid
WA2104909Medicaid
WAG000105022Medicare PIN