Provider Demographics
NPI:1417185349
Name:JACOB T. SMITH, O.D. PLLC
Entity Type:Organization
Organization Name:JACOB T. SMITH, O.D. PLLC
Other - Org Name:DR. SMITH'S OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:T
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-447-5001
Mailing Address - Street 1:3720 W ROBINSON ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3657
Mailing Address - Country:US
Mailing Address - Phone:405-447-5001
Mailing Address - Fax:405-447-4680
Practice Address - Street 1:3720 W ROBINSON ST
Practice Address - Street 2:SUITE 118
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-3657
Practice Address - Country:US
Practice Address - Phone:405-447-5001
Practice Address - Fax:405-447-4680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACOB T. SMITH, O.D. PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2503332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200112670AMedicaid
OK200112670AMedicaid