Provider Demographics
NPI:1437286713
Name:SMITH, WILLIE DARRELL (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:DARRELL
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 1:1357 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-4352
Mailing Address - Country:US
Mailing Address - Phone:517-263-0424
Mailing Address - Fax:517-263-6379
Practice Address - Street 1:1357 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-4352
Practice Address - Country:US
Practice Address - Phone:517-263-0424
Practice Address - Fax:517-263-6379
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI490100002985152W00000X, 152WC0802X, 152WL0500X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4248362Medicaid
MIPH15592Medicaid
MIPH15592Medicaid
MI4248362Medicaid