Provider Demographics
NPI:1366483612
Name:SMITH, BRIAN DARRELL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DARRELL
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 1:1301 COUNTY ROAD G
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54858-2915
Mailing Address - Country:US
Mailing Address - Phone:715-825-3974
Mailing Address - Fax:
Practice Address - Street 1:1301 COUNTY ROAD G
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:WI
Practice Address - Zip Code:54858-2915
Practice Address - Country:US
Practice Address - Phone:715-825-3974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2728152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000005115Medicare ID - Type Unspecified
WIU74072Medicare UPIN