Provider Demographics
NPI:1750905964
Name:SMITH, KELSEY DEBORAH (OD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:DEBORAH
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 1:24 SATO STREET
Mailing Address - Street 2:
Mailing Address - City:WHITBY
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L1R2E6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 OLD TROLLEY RD STE 3
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5287
Practice Address - Country:US
Practice Address - Phone:843-873-1889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003591152W00000X
SC2361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist