Provider Demographics
NPI:1437144037
Name:SMITH, MARK ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
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 1:15821 SR 525
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-9780
Mailing Address - Country:US
Mailing Address - Phone:360-321-4779
Mailing Address - Fax:360-321-4782
Practice Address - Street 1:15821 SR 525
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9780
Practice Address - Country:US
Practice Address - Phone:360-321-4779
Practice Address - Fax:360-321-4782
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080307Medicaid
WAT02893Medicare UPIN
WA2080307Medicaid
WAG001100035Medicare PIN