Provider Demographics
NPI:1437329190
Name:SMITH, JUSTIN BRADLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:BRADLEY
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 1:330 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2129
Mailing Address - Country:US
Mailing Address - Phone:978-287-9494
Mailing Address - Fax:978-287-9404
Practice Address - Street 1:330 BAKER AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2129
Practice Address - Country:US
Practice Address - Phone:978-287-9494
Practice Address - Fax:978-287-9404
Is Sole Proprietor?:No
Enumeration Date:2008-03-08
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4654152W00000X, 152WV0400X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0729787Medicaid
MA0729787Medicaid