Provider Demographics
NPI:1851392054
Name:SMITH, MARK LEONARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEONARD
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 1:2500 MARIETTA RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9458
Mailing Address - Country:US
Mailing Address - Phone:740-775-6195
Mailing Address - Fax:740-775-6195
Practice Address - Street 1:2500 MARIETTA RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9458
Practice Address - Country:US
Practice Address - Phone:740-775-6195
Practice Address - Fax:740-775-6195
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3440 T159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0681927Medicaid
OH0681927Medicaid
OH0606371Medicare PIN