Provider Demographics
NPI:1578624813
Name:SMITH, KRIS EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:EDWARD
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 1:792 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-4701
Mailing Address - Country:US
Mailing Address - Phone:772-770-2020
Mailing Address - Fax:772-770-4617
Practice Address - Street 1:792 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-4701
Practice Address - Country:US
Practice Address - Phone:772-770-2020
Practice Address - Fax:772-770-4617
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT54808Medicare UPIN
FL20158Medicare ID - Type Unspecified