Provider Demographics
NPI:1619190923
Name:SMITH, COURTNEY DAELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:DAELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10294 EMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-9456
Mailing Address - Country:US
Mailing Address - Phone:563-587-0133
Mailing Address - Fax:
Practice Address - Street 1:555 JOHN F KENNEDY RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-5202
Practice Address - Country:US
Practice Address - Phone:563-589-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist