Provider Demographics
NPI:1316014582
Name:SMITH, GARY STEVEN (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:STEVEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948-9355
Mailing Address - Country:US
Mailing Address - Phone:252-441-2000
Mailing Address - Fax:252-441-1834
Practice Address - Street 1:2400 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948-9355
Practice Address - Country:US
Practice Address - Phone:252-441-2000
Practice Address - Fax:252-441-1834
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1462156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802077Medicaid
NC5461780001Medicare ID - Type Unspecified