Provider Demographics
NPI:1659485373
Name:SMITH, VIVIEN MARY (OD)
Entity Type:Individual
Prefix:DR
First Name:VIVIEN
Middle Name:MARY
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:PO BOX 910824
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-0824
Mailing Address - Country:US
Mailing Address - Phone:859-224-8083
Mailing Address - Fax:859-223-2913
Practice Address - Street 1:3735 PALOMAR CENTRE DR
Practice Address - Street 2:SUITE #45
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1147
Practice Address - Country:US
Practice Address - Phone:859-224-8083
Practice Address - Fax:859-223-2913
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1223DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77012235Medicaid
KY9307601Medicare PIN
U21248Medicare UPIN