Provider Demographics
NPI:1285687442
Name:SMITH, RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
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 1:601 GALVIN RD S
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-2249
Mailing Address - Country:US
Mailing Address - Phone:402-293-1840
Mailing Address - Fax:
Practice Address - Street 1:601 GALVIN RD S
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-2249
Practice Address - Country:US
Practice Address - Phone:402-293-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NET40303Medicare UPIN
NE278448Medicare ID - Type Unspecified