Provider Demographics
NPI:1760795231
Name:SMITH, JONATHAN HAROLD (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:HAROLD
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 1:997 PRESTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4138
Mailing Address - Country:US
Mailing Address - Phone:618-659-0297
Mailing Address - Fax:
Practice Address - Street 1:10840 LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2010
Practice Address - Country:US
Practice Address - Phone:618-397-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist