Provider Demographics
NPI:1477513448
Name:SMITH, RICHARD E (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
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 1:3201 W STATE ROAD 45
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5107
Mailing Address - Country:US
Mailing Address - Phone:812-339-2933
Mailing Address - Fax:812-332-6065
Practice Address - Street 1:3201 W STATE ROAD 45
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5107
Practice Address - Country:US
Practice Address - Phone:812-339-2933
Practice Address - Fax:812-332-6065
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001827B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN549180Medicare ID - Type Unspecified
INU70222Medicare UPIN