Provider Demographics
NPI:1255369138
Name:SMITH, ALLEN RALPH (OD)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:RALPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8636 CARLISLE DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8167
Mailing Address - Country:US
Mailing Address - Phone:616-583-1424
Mailing Address - Fax:
Practice Address - Street 1:597 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-7994
Practice Address - Country:US
Practice Address - Phone:616-457-0760
Practice Address - Fax:616-457-0762
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV05731Medicare UPIN
MIN96950002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER