Provider Demographics
NPI:1912937251
Name:SMITH, PAUL W (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:780 W OLIVE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2437
Mailing Address - Country:US
Mailing Address - Phone:209-384-2101
Mailing Address - Fax:209-384-8023
Practice Address - Street 1:780 W OLIVE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2437
Practice Address - Country:US
Practice Address - Phone:209-384-2101
Practice Address - Fax:209-384-8023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA09431T152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094310Medicaid
CASD0094310Medicare ID - Type Unspecified
CASD0094310Medicaid
CA5750680001Medicare NSC