Provider Demographics
NPI:1134156144
Name:SMALL, CRAIG K (OD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:K
Last Name:SMALL
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 1:37 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-2426
Mailing Address - Country:US
Mailing Address - Phone:207-496-5111
Mailing Address - Fax:207-498-6502
Practice Address - Street 1:37 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-2426
Practice Address - Country:US
Practice Address - Phone:207-496-5111
Practice Address - Fax:207-498-6502
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT736152W00000X, 152WP0200X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010429521OtherPROVIDER ID
ME0253910001OtherDMERC PROVIDER ID
MEP00071063OtherRAILROAD MEDICARE ID
ME118340099Medicaid
MET31328Medicare UPIN
MEP00071063OtherRAILROAD MEDICARE ID