Provider Demographics
NPI:1720128572
Name:SMITH, GARY LOCKE (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LOCKE
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 1:1013 N 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2664
Mailing Address - Country:US
Mailing Address - Phone:706-232-6767
Mailing Address - Fax:706-291-4677
Practice Address - Street 1:1013 N 5TH AVE NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2664
Practice Address - Country:US
Practice Address - Phone:706-232-6767
Practice Address - Fax:706-291-4677
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000687152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581444484OtherFEDERAL ID
GA000004727Medicaid
GAGA000687OtherSTATE LICENSE
GAMSO126272OtherDEA
GAGA000687OtherSTATE LICENSE
GA41ZCBPBMedicare ID - Type Unspecified
GA000004727Medicaid