Provider Demographics
NPI:1376506402
Name:SMITH, JOHN WL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WL
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:531 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3701
Mailing Address - Country:US
Mailing Address - Phone:803-279-5277
Mailing Address - Fax:803-279-0699
Practice Address - Street 1:531 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3701
Practice Address - Country:US
Practice Address - Phone:803-279-5277
Practice Address - Fax:803-279-0699
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T246157127Medicare PIN
0658800001Medicare NSC
T24615Medicare UPIN