Provider Demographics
NPI:1568503837
Name:SMILEY, THEODORE (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:SMILEY
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 1:4775 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4313
Mailing Address - Country:US
Mailing Address - Phone:614-459-0600
Mailing Address - Fax:614-459-8750
Practice Address - Street 1:4775 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4313
Practice Address - Country:US
Practice Address - Phone:614-459-0600
Practice Address - Fax:614-459-8750
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3203-1015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0305762Medicaid
OH0305762Medicaid
OHSM0466474Medicare ID - Type Unspecified