Provider Demographics
NPI:1841224987
Name:SMITH, TIMOTHY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
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 1:112A WESTWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1181
Mailing Address - Country:US
Mailing Address - Phone:816-781-2220
Mailing Address - Fax:816-781-2854
Practice Address - Street 1:112A WESTWOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1181
Practice Address - Country:US
Practice Address - Phone:816-781-2220
Practice Address - Fax:816-781-2854
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42528Medicare UPIN
MOR890792Medicare ID - Type Unspecified