Provider Demographics
NPI:1952461352
Name:SMITH, JEFFREY E (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
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 1:13855 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3664
Mailing Address - Country:US
Mailing Address - Phone:763-421-0141
Mailing Address - Fax:763-421-0334
Practice Address - Street 1:13855 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3664
Practice Address - Country:US
Practice Address - Phone:763-421-0141
Practice Address - Fax:763-421-0334
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1554152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN114915OtherUCARE
MN56582330Medicaid
MN16125OtherHEALTH PARTNERS
MN59780ANOtherBCBS
FM2215383OtherMEDICA
MN747001OtherPREFERREDONE
MN56582330Medicaid