Provider Demographics
NPI:1649603572
Name:SMITH, JEDIDIAH DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:DAVID
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 1:1945 E BRANDON PARK WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5234
Mailing Address - Country:US
Mailing Address - Phone:801-842-1728
Mailing Address - Fax:
Practice Address - Street 1:1818 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1805
Practice Address - Country:US
Practice Address - Phone:801-485-9715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010703152W00000X
UT9488924-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist