Provider Demographics
NPI:1982697207
Name:SMART, RANDY DELL (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:DELL
Last Name:SMART
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 1:1518 W BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-1817
Mailing Address - Country:US
Mailing Address - Phone:805-489-8467
Mailing Address - Fax:805-489-8612
Practice Address - Street 1:1518 W BRANCH ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-1817
Practice Address - Country:US
Practice Address - Phone:805-489-8467
Practice Address - Fax:805-489-8612
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6555TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0065551Medicaid
CAOP6555AMedicare PIN
CA0224840001Medicare NSC
CASD0065551Medicaid