Provider Demographics
NPI:1487681540
Name:SMITH, ANDRE HAROLD
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:HAROLD
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 LIBERTY HTS. AVE.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7442
Mailing Address - Country:US
Mailing Address - Phone:410-664-9436
Mailing Address - Fax:443-524-2302
Practice Address - Street 1:3020 LIBERTY HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7442
Practice Address - Country:US
Practice Address - Phone:410-664-9436
Practice Address - Fax:443-524-2302
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0201840001Medicare ID - Type Unspecified