Provider Demographics
NPI:1609828581
Name:SMITH, LAWRENCE W (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2925 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-5004
Mailing Address - Country:US
Mailing Address - Phone:262-308-0027
Mailing Address - Fax:262-308-0027
Practice Address - Street 1:5684 N. CENTER PARK WAY
Practice Address - Street 2:BAYSHORE TOWN CENTER
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-1320
Practice Address - Country:US
Practice Address - Phone:414-962-2021
Practice Address - Fax:414-962-2021
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2331035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U33809Medicare UPIN