1760795231 NPI number — DR. JONATHAN HAROLD SMITH O.D.

Table of content: DR. JONATHAN HAROLD SMITH O.D. (NPI 1760795231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760795231 NPI number — DR. JONATHAN HAROLD SMITH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JONATHAN
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1760795231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
997 PRESTONWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDWARDSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62025-4138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-659-0297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10840 LINCOLN TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRVIEW HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62208-2010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-397-8880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2010

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:  046010386 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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