Healthcare Provider Details

I. General information

NPI: 1356573141
Provider Name (Legal Business Name): TIMOTHY JOHN SMITH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 S GOVERNORS AVE
DOVER DE
19904-4158
US

IV. Provider business mailing address

885 S GOVERNORS AVE
DOVER DE
19904-4158
US

V. Phone/Fax

Practice location:
  • Phone: 302-734-1472
  • Fax: 302-734-1921
Mailing address:
  • Phone: 302-734-1472
  • Fax: 302-734-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberI3-0001338
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: