Provider Demographics
NPI:1134819543
Name:SMITH, ANGELA (LDO)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6810 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-2390
Mailing Address - Country:US
Mailing Address - Phone:863-797-5066
Mailing Address - Fax:863-701-2595
Practice Address - Street 1:6745 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-2080
Practice Address - Country:US
Practice Address - Phone:863-701-2573
Practice Address - Fax:863-701-2595
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLDO3518156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician