Provider Demographics
NPI:1558419325
Name:SMITH, ROBERT CARL (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CARL
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:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:618-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009880152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00418703OtherMEDICARE RAILROAD
IL0814870028OtherMEDICARE NSC NUMBER
IL046009880Medicaid
IL0814870001OtherMEDICARE NSC NUMBER
IL0814870031OtherMEDICARE NSC NUMBER
IL0814870029OtherMEDICARE NSC NUMBER
133825OtherHEALTH ALLIANCE
IL9880OtherEYEMED
IL0814870029OtherMEDICARE NSC NUMBER
IL046009880Medicaid