Provider Demographics
NPI:1023083326
Name:SMITH, LARRY DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DEAN
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 1:914 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-4530
Mailing Address - Country:US
Mailing Address - Phone:319-372-5181
Mailing Address - Fax:319-372-0865
Practice Address - Street 1:914 AVENUE G
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-4530
Practice Address - Country:US
Practice Address - Phone:319-372-5181
Practice Address - Fax:319-372-0865
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0044214Medicaid
IA09894Medicare ID - Type Unspecified
IAT-00736Medicare UPIN