Provider Demographics
NPI:1487844536
Name:KEVIN SMITH OD AND ASSOCIATES INC
Entity Type:Organization
Organization Name:KEVIN SMITH OD AND ASSOCIATES INC
Other - Org Name:SOUTH TAMPA EYE SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-312-1174
Mailing Address - Street 1:4117 HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5749
Mailing Address - Country:US
Mailing Address - Phone:813-207-8984
Mailing Address - Fax:813-207-8954
Practice Address - Street 1:4117 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5749
Practice Address - Country:US
Practice Address - Phone:813-207-8984
Practice Address - Fax:813-207-8954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3456152WC0802X
FLOPC 3456332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11221087OtherCAQH
FL620814201Medicaid
FL11221087OtherCAQH
FLAJ611Medicare PIN
5929060001Medicare NSC