Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1014 | OK |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 1014 | OK |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | 1014 | OK |
N | 152WP0200X | Pediatric Optomitrist | 1014 | OK |
N | 152WS0006X | Sports Vision | 1014 | OK |
N | 152WV0400X | Optomitrist - Vision Therapist | 1014 | OK |
N | 152WX0102X | Occupational Vision | 1014 | OK |
NPI | 1043277791 |
---|---|
Provider Name | John O. Smith |
First Address | Hennessey, OK 73742-0654 |
Second Address | Hennessey, OK 73742-1744 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2006 |
Last Update Date | 03/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
731129821001 | BCBS PAYER ID (01) | OK |
T40656 | (02) | OK |