Provider Demographics
NPI:1952497679
Name:SMITH, MARK P (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
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 1:211 NORTH WHITWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601
Mailing Address - Country:US
Mailing Address - Phone:601-833-4431
Mailing Address - Fax:601-833-1007
Practice Address - Street 1:211 NORTH WHITWORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601
Practice Address - Country:US
Practice Address - Phone:601-833-4431
Practice Address - Fax:601-833-1007
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700288OtherMEDICARE PTAN
MS09125722Medicaid
MS512G700288OtherMEDICARE PTAN