Provider Demographics
NPI:1376957043
Name:SMITH, TREVOR ALAN (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 MAIN ST SW STE 140
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9697
Mailing Address - Country:US
Mailing Address - Phone:616-287-5495
Mailing Address - Fax:
Practice Address - Street 1:2225 MAIN ST SW STE 140
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9697
Practice Address - Country:US
Practice Address - Phone:616-287-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301117194207W00000X
OH35.133431207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0277191Medicaid