Provider Demographics
NPI:1912029646
Name:SMITH, SUZANNE KATHLEEN (OD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:KATHLEEN
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:PO BOX 1155
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:33860-1155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4485 MEADOWOOD DR
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-6636
Practice Address - Country:US
Practice Address - Phone:863-647-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002392152W00000X
MN2898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU17632Medicare UPIN