Provider Demographics
NPI:1508814252
Name:SIRAK-SMITH, JESSICA FAYE (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:FAYE
Last Name:SIRAK-SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 BAYLOR DR STE 104
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-8903
Mailing Address - Country:US
Mailing Address - Phone:843-706-3022
Mailing Address - Fax:
Practice Address - Street 1:80 BAYLOR DR STE 104
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8903
Practice Address - Country:US
Practice Address - Phone:843-706-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2053152W00000X
PAOEG000195152W00000X
SC1260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA920135949AMedicaid
SCDA9560OtherMEDICAID, GROUP
SCDG2053Medicaid
SCSC2493E499OtherMEDICARE
SCDG2053Medicaid
SCSC2493E499OtherMEDICARE