Provider Demographics
NPI:1881619955
Name:SMITH, KELLY A (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2040
Mailing Address - Country:US
Mailing Address - Phone:334-793-2211
Mailing Address - Fax:334-793-7161
Practice Address - Street 1:607 BOLL WEEVIL CIR STE C
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2733
Practice Address - Country:US
Practice Address - Phone:334-347-6599
Practice Address - Fax:334-417-0190
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4065152W00000X, 152WC0802X, 152WP0200X
ALS-B14-TA-705152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621068600Medicaid
AL240878Medicaid
FLP0030826OtherRR MEDICARE
FL28556OtherBLUE CROSS & BLUE SHIELD
FL621068600Medicaid