Provider Demographics
NPI:1407997059
Name:SMITH, KIMBERLY D (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6441 EDGEBROOK CT
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040
Mailing Address - Country:US
Mailing Address - Phone:513-459-9495
Mailing Address - Fax:
Practice Address - Street 1:245 N MAIN ST
Practice Address - Street 2:STE 300
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9171
Practice Address - Country:US
Practice Address - Phone:937-748-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9348121OtherGROUP MEDICARE PIN
OH4101736Medicare PIN
OH4094500001Medicare NSC
OHU50848Medicare UPIN