Provider Demographics
NPI:1457304818
Name:SMITH, ALEX JONATHAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:JONATHAN
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 1:25500 N. NORTERRA PARKWAY, BLDG B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085
Mailing Address - Country:US
Mailing Address - Phone:623-277-1000
Mailing Address - Fax:602-906-2789
Practice Address - Street 1:1920 E. BASELINE ROAD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283
Practice Address - Country:US
Practice Address - Phone:480-345-5085
Practice Address - Fax:408-345-5266
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1570152WV0400X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032233Medicaid
OR240471Medicaid
WA8861483Medicare Oscar/Certification
OR240471Medicaid
AZZ127522Medicare PIN
OR135171Medicare Oscar/Certification