Provider Demographics
NPI:1417067950
Name:SMITH, DAVID ALAN (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
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 1:276 NO. SPRING CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9707
Mailing Address - Country:US
Mailing Address - Phone:435-713-4444
Mailing Address - Fax:435-787-1238
Practice Address - Street 1:276 N. SPRINGCREEK PKWY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9707
Practice Address - Country:US
Practice Address - Phone:435-713-4444
Practice Address - Fax:435-787-1238
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346644-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT615808OtherDMBA
UTUT6644OtherEYEMED
UT61391OtherPEHP
UTPRA03690OtherMOLINA
UTQM0000053383OtherALTIUS
UT3999070001OtherDMERC
UT615808OtherDMBA
UT3999070001Medicare NSC
UT3999070001OtherDMERC
UT615808OtherDMBA