Provider Demographics
NPI:1376681692
Name:SMITH, JONATHAN (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:780 NORTHWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89451-8209
Mailing Address - Country:US
Mailing Address - Phone:775-831-4131
Mailing Address - Fax:775-831-4165
Practice Address - Street 1:780 NORTHWOOD BLVD
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-8209
Practice Address - Country:US
Practice Address - Phone:775-831-4131
Practice Address - Fax:775-831-4165
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1689888992OtherNPPES TYPE II ORGANIZATION/GROUP NPI
NV0177380002OtherSUPPLIER NUMBER
NV88-0264965OtherTIN
NV0177380002OtherSUPPLIER NUMBER
NVU17153Medicare UPIN