Provider Demographics
NPI:1831385756
Name:SMITH, MISTI STAPLETON (OD)
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:STAPLETON
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MISTI
Other - Middle Name:RENEA
Other - Last Name:STAPLETON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:3801 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2418
Practice Address - Country:US
Practice Address - Phone:478-475-1600
Practice Address - Fax:478-475-1876
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002429152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist