Provider Demographics
NPI:1770845489
Name:SMOUSE, CODY (OD)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:SMOUSE
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 1:894 WYNFORD CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9785
Mailing Address - Country:US
Mailing Address - Phone:724-689-5073
Mailing Address - Fax:
Practice Address - Street 1:112 RUTLEDGE AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1333
Practice Address - Country:US
Practice Address - Phone:843-577-2674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist