Provider Demographics
NPI:1427044031
Name:SMITH, MARTHA S (OD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:S
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 1:113 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:IA
Mailing Address - Zip Code:52031-1307
Mailing Address - Country:US
Mailing Address - Phone:563-872-5975
Mailing Address - Fax:563-872-3248
Practice Address - Street 1:113 STATE ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:IA
Practice Address - Zip Code:52031-1307
Practice Address - Country:US
Practice Address - Phone:563-872-5975
Practice Address - Fax:563-872-3248
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02080152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0221804Medicaid
IAU67943Medicare UPIN
IA3929700001Medicare NSC
IA41207Medicare PIN