Healthcare Provider Details

I. General information

NPI: 1053644666
Provider Name (Legal Business Name): SMITH BLANC O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18610 NW 67TH AVE
HIALEAH FL
33015-2406
US

IV. Provider business mailing address

10860 NW 37TH CT
CORAL SPRINGS FL
33065-2701
US

V. Phone/Fax

Practice location:
  • Phone: 305-474-0463
  • Fax: 305-474-8071
Mailing address:
  • Phone: 786-897-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4425
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC4425
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: