Provider Demographics
NPI:1760426167
Name:SMITH, JOHN R (OD, MS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:PA
Mailing Address - Zip Code:19526-1823
Mailing Address - Country:US
Mailing Address - Phone:610-562-4548
Mailing Address - Fax:610-562-1358
Practice Address - Street 1:260 STATE ST
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:PA
Practice Address - Zip Code:19526-1823
Practice Address - Country:US
Practice Address - Phone:610-562-4548
Practice Address - Fax:610-562-1358
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000269152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50003676OtherBLUE CROSS
PA679971OtherBLUE SHIELD
PA0468760001Medicare NSC
PA679971OtherBLUE SHIELD
PA679971Medicare PIN