Provider Demographics
NPI:1588805444
Name:DR. GRAY R. SMITH, INC.
Entity Type:Organization
Organization Name:DR. GRAY R. SMITH, INC.
Other - Org Name:SOUTH LAKE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:GRAY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-243-5349
Mailing Address - Street 1:2250 E HIGHWAY 50
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6052
Mailing Address - Country:US
Mailing Address - Phone:352-243-5348
Mailing Address - Fax:352-243-8358
Practice Address - Street 1:2250 E HIGHWAY 50
Practice Address - Street 2:SUITE 1
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6052
Practice Address - Country:US
Practice Address - Phone:352-243-5348
Practice Address - Fax:352-243-8358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3661152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL880BMedicare PIN