Healthcare Provider Details

I. General information

NPI: 1942550256
Provider Name (Legal Business Name): GARY L SMITH OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N 5TH AVE NE STE 4
ROME GA
30165-2664
US

IV. Provider business mailing address

1013 N 5TH AVE NE STE 4
ROME GA
30165-2664
US

V. Phone/Fax

Practice location:
  • Phone: 706-232-6767
  • Fax: 706-291-4677
Mailing address:
  • Phone: 706-232-6767
  • Fax: 706-291-4677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT000687
License Number StateGA

VIII. Authorized Official

Name: DR. GARY L SMITH
Title or Position: OWNER
Credential: OD, PC
Phone: 706-232-6767