Provider Demographics
NPI:1356573141
Name:SMITH, TIMOTHY JOHN (OD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
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 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-1472
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-1472
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1245251313OtherGRP NPI
DE13-0001338OtherDE PROFESSIONAL LICENSE
DEG00016OtherMEDICARE GROUP ID