Provider Demographics
NPI:1891735932
Name:SMITH, KEVIN D (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
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 1:11720 OLIO RD
Mailing Address - Street 2:STE 500
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7623
Mailing Address - Country:US
Mailing Address - Phone:317-570-8100
Mailing Address - Fax:
Practice Address - Street 1:11720 OLIO RD
Practice Address - Street 2:STE 500
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7623
Practice Address - Country:US
Practice Address - Phone:317-570-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003321B152W00000X, 152WC0802X, 152WS0006X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN254210AMedicare PIN