Healthcare Provider Details

I. General information

NPI: 1457304818
Provider Name (Legal Business Name): ALEX JONATHAN SMITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E. BASELINE ROAD
TEMPE AZ
85283
US

IV. Provider business mailing address

25500 N. NORTERRA PARKWAY, BLDG B
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 480-345-5085
  • Fax: 408-345-5266
Mailing address:
  • Phone: 623-277-1000
  • Fax: 602-906-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1570
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1570
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1570
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: