Provider Demographics
NPI:1497909550
Name:SMITH, BENJAMIN DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
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 1:1041 ACOMA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4034
Mailing Address - Country:US
Mailing Address - Phone:720-255-2412
Mailing Address - Fax:720-536-8283
Practice Address - Street 1:1041 ACOMA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4034
Practice Address - Country:US
Practice Address - Phone:720-255-2412
Practice Address - Fax:720-536-8283
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2881152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50824066Medicaid
323010ZH3Medicare PIN
AZ516799Medicaid
NMP00841383OtherMEDICARE RAILROAD CARRIER
CO0422000001Medicare NSC