MEDICARE: JEFFERY SMITH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1980-035	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366508285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY SMITH OD

Provider Business Mailing Address
First Line	:	11103 WEST AVE
Second Line	:	SUITE 6
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1370
Country	:	US
Telephone Number	:	210-524-6663
Fax Number	:	210-524-6587

Provider Business Practice Location Address
First Line	:	5530 N PORT WASHINGTON RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53217-4920
Country	:	US
Telephone Number	:	414-332-1114
Fax Number	:	414-332-5169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/09/2007

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