Provider Demographics
NPI:1730128844
Name:SMITH, BRUCE R (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15140 SMARTY JONES DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-5666
Mailing Address - Country:US
Mailing Address - Phone:219-776-6804
Mailing Address - Fax:219-663-2398
Practice Address - Street 1:30 1ST ST SW
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2102
Practice Address - Country:US
Practice Address - Phone:317-848-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001702B152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
U28560Medicare UPIN
250340-AMedicare PIN