Provider Demographics
NPI:1013117159
Name:SMITH, EMILY (OD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
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 1:904 W SPRINGFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1213
Mailing Address - Country:US
Mailing Address - Phone:217-287-2020
Mailing Address - Fax:217-824-2228
Practice Address - Street 1:1200 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4437
Practice Address - Country:US
Practice Address - Phone:618-993-5686
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0814870032OtherMEDICARE NSC NUMBER
ILP00454765, CB9582OtherMEDICARE RAILROAD
IL0814870028OtherMEDICARE NSC NUMBER
IL0814870001OtherMEDICARE NSC NUMBER
IL9974OtherEYEMED
IL0814870027OtherMEDICARE NSC NUMBER
IL046009974Medicaid
IL0814870029OtherMEDICARE NSC NUMBER
135537OtherHEALTH ALLIANCE
135537OtherHEALTH ALLIANCE