1104906759 NPI number — MRS. TAMARA SMITH OLD O.D.

Table of content: MRS. TAMARA SMITH OLD O.D. (NPI 1104906759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104906759 NPI number — MRS. TAMARA SMITH OLD O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLD
Provider First Name:
TAMARA
Provider Middle Name:
SMITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
TAMARA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104906759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4874 SPARKS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89436-8206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-358-1317
Provider Business Mailing Address Fax Number:
775-355-7522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4874 SPARKS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89436-8206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-358-1317
Provider Business Practice Location Address Fax Number:
775-355-7522
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  415 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V100563 . This is a "MEDICARE ID-PIN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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