Provider Demographics
NPI:1588807028
Name:JACOB T SMITH OD PLLC
Entity Type:Organization
Organization Name:JACOB T SMITH OD PLLC
Other - Org Name:CLASSIC VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-447-5001
Mailing Address - Street 1:3720 W ROBINSON ST
Mailing Address - Street 2:STE 118
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3640
Mailing Address - Country:US
Mailing Address - Phone:405-447-5001
Mailing Address - Fax:405-447-4680
Practice Address - Street 1:3720 W ROBINSON ST
Practice Address - Street 2:STE 118
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-3640
Practice Address - Country:US
Practice Address - Phone:405-447-5001
Practice Address - Fax:405-447-4680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKB5591OtherGROUP PTAN
OK200112670AMedicaid
OK6264910001Medicare NSC