Provider Demographics
NPI:1447235742
Name:SMITH, CLEO HERBERT JR (OD)
Entity Type:Individual
Prefix:DR
First Name:CLEO
Middle Name:HERBERT
Last Name:SMITH
Suffix:JR
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 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:584 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4573
Practice Address - Country:US
Practice Address - Phone:704-782-0677
Practice Address - Fax:704-262-9772
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC604152W00000X
NC0986152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909848Medicaid
NC890181PMedicaid
NC8909848Medicaid
NC246326BMedicare ID - Type UnspecifiedINDIVIDUAL
NC1014480001Medicare NSC