Provider Demographics
NPI:1124046735
Name:SMITH, MARK P (OD)
Entity type:Individual
Prefix:
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:PO BOX 11407
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-5323
Mailing Address - Country:US
Mailing Address - Phone:706-323-3491
Mailing Address - Fax:706-660-9191
Practice Address - Street 1:6600 WHITTLESEY BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-7337
Practice Address - Country:US
Practice Address - Phone:706-323-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00451162FMedicaid
GA41ZCBZK01Medicare ID - Type Unspecified
GAT88257Medicare UPIN