Provider Demographics
NPI:1265760680
Name:FREDERICK EYE CARE PLLC
Entity type:Organization
Organization Name:FREDERICK EYE CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-335-2020
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73802-0187
Mailing Address - Country:US
Mailing Address - Phone:580-254-8020
Mailing Address - Fax:580-254-8377
Practice Address - Street 1:1009 TEXAS ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3127
Practice Address - Country:US
Practice Address - Phone:580-254-8020
Practice Address - Fax:580-254-8377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK EYE CARE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-23
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522354Medicare PIN