Provider Demographics
NPI:1841374386
Name:SMITH, JAMES STANLEY (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:STANLEY
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 1:833 LEONARD ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4147
Mailing Address - Country:US
Mailing Address - Phone:616-458-7978
Mailing Address - Fax:616-458-3719
Practice Address - Street 1:833 LEONARD ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4147
Practice Address - Country:US
Practice Address - Phone:616-458-7978
Practice Address - Fax:616-458-3719
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5038350Medicaid
MI5038350Medicaid
MIOD16571Medicare PIN
MI410004935Medicare PIN
MI0825790001Medicare NSC