Provider Demographics
NPI:1184690877
Name:SMITH, PHILIP L (OD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:L
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 1:1100 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4701
Mailing Address - Country:US
Mailing Address - Phone:210-222-2154
Mailing Address - Fax:210-227-6056
Practice Address - Street 1:1100 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4701
Practice Address - Country:US
Practice Address - Phone:210-222-2154
Practice Address - Fax:210-227-6056
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04549TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137341701Medicaid
TX410038679OtherRAILROAD MEDICARE
TX410038679OtherRAILROAD MEDICARE
TX137341701Medicaid