Provider Demographics
NPI:1558369108
Name:SMITH, MARY LOU (OD)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name: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:PO BOX 2410
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33779-2410
Mailing Address - Country:US
Mailing Address - Phone:727-581-8706
Mailing Address - Fax:727-586-3743
Practice Address - Street 1:148 13TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3127
Practice Address - Country:US
Practice Address - Phone:727-581-8706
Practice Address - Fax:727-586-3743
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078988700Medicaid
20447UMedicare PIN
U20747Medicare UPIN