Provider Demographics
NPI:1518995075
Name:SMITH, ROBERT ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLEN
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 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 MILK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-4806
Practice Address - Country:US
Practice Address - Phone:617-654-7150
Practice Address - Fax:617-654-7169
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0350354Medicaid
MAW15140OtherBLUECROSS BLUESHIELD
MA0350354Medicaid
MAQX4176Medicare PIN