1417185349 NPI number — JACOB T. SMITH, O.D. PLLC

Table of content: (NPI 1417185349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417185349 NPI number — JACOB T. SMITH, O.D. PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACOB T. SMITH, O.D. PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. SMITH'S OPTICAL
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417185349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3720 W ROBINSON ST
Provider Second Line Business Mailing Address:
SUITE 118
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73072-3657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-447-5001
Provider Business Mailing Address Fax Number:
405-447-4680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3720 W ROBINSON ST
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73072-3657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-447-5001
Provider Business Practice Location Address Fax Number:
405-447-4680
Provider Enumeration Date:
06/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER/OPTOMETRIST
Authorized Official Telephone Number:
405-447-5001

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  2503 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200112670A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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