Provider Demographics
NPI:1396758017
Name:SMITH, GREGORY MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1 HICKORY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-1402
Mailing Address - Country:US
Mailing Address - Phone:215-850-7892
Mailing Address - Fax:703-784-1635
Practice Address - Street 1:3259 CATLIN AVE
Practice Address - Street 2:NAVAL MEDICAL CLINIC QUANTICO
Practice Address - City:QUANTICO
Practice Address - State:VA
Practice Address - Zip Code:22134
Practice Address - Country:US
Practice Address - Phone:703-784-1634
Practice Address - Fax:703-784-1635
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1880196OtherUNITED STATES NAVY