Provider Demographics
NPI:1457569378
Name:SMITH, ANGELA SUE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 S MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1939
Mailing Address - Country:US
Mailing Address - Phone:218-281-2020
Mailing Address - Fax:218-281-5997
Practice Address - Street 1:216 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1939
Practice Address - Country:US
Practice Address - Phone:218-281-2020
Practice Address - Fax:218-281-5997
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3062035152W00000X
MN3074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38632000Medicaid
MN1457569378Medicaid
WI38632000Medicaid
MN410003778Medicare PIN