Provider Demographics
NPI:1710463872
Name:SMITH, MITCHELL G (OD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 W. MAIN ST.
Mailing Address - Street 2:APT. 112
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368
Mailing Address - Country:US
Mailing Address - Phone:219-851-4637
Mailing Address - Fax:
Practice Address - Street 1:1601 E 81ST AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-750-9673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004117A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist