Healthcare Provider Details

I. General information

NPI: 1184674152
Provider Name (Legal Business Name): J. KYLE SMITH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N MCPHERSON ST
FORT BRAGG CA
95437-3314
US

IV. Provider business mailing address

450 N MCPHERSON ST
FORT BRAGG CA
95437-3314
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-5927
  • Fax: 707-964-6533
Mailing address:
  • Phone: 707-964-5927
  • Fax: 707-964-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number11804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number11804
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number11804
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: