Healthcare Provider Details

I. General information

NPI: 1487844536
Provider Name (Legal Business Name): KEVIN SMITH OD AND ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 HENDERSON BLVD
TAMPA FL
33629-5749
US

IV. Provider business mailing address

4117 HENDERSON BLVD
TAMPA FL
33629-5749
US

V. Phone/Fax

Practice location:
  • Phone: 813-207-8984
  • Fax: 813-207-8954
Mailing address:
  • Phone: 813-207-8984
  • Fax: 813-207-8954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPC 3456
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC3456
License Number StateFL

VIII. Authorized Official

Name: DR. KEVIN L SMITH
Title or Position: OPTOMETRIST
Credential: OD
Phone: 813-312-1174