Provider Demographics
NPI:1487655437
Name:SMITH, TONY SHAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:SHAWN
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 1:1225 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-4989
Mailing Address - Country:US
Mailing Address - Phone:270-251-2020
Mailing Address - Fax:270-247-8652
Practice Address - Street 1:1225 PARIS RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-4989
Practice Address - Country:US
Practice Address - Phone:270-251-2020
Practice Address - Fax:270-247-8652
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1391DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013910Medicaid
KY1968101Medicare PIN
U79813Medicare UPIN