Provider Demographics
NPI:1790129633
Name:SMITH, PRUDENCE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCE
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5886 ARLENE WAY
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-8144
Mailing Address - Country:US
Mailing Address - Phone:925-454-0199
Mailing Address - Fax:
Practice Address - Street 1:5886 ARLENE WAY
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-8144
Practice Address - Country:US
Practice Address - Phone:925-454-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist