Provider Demographics
NPI:1629179791
Name:SMITH, LEESA HOGG (OD)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:HOGG
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 1:1607 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7832
Mailing Address - Country:US
Mailing Address - Phone:662-378-2085
Mailing Address - Fax:662-334-4593
Practice Address - Street 1:1607 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7832
Practice Address - Country:US
Practice Address - Phone:662-378-2085
Practice Address - Fax:662-334-4593
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880066Medicaid
MST91823Medicare UPIN
MS00880066Medicaid
MS410000149Medicare ID - Type Unspecified