Healthcare Provider Details

I. General information

NPI: 1639241060
Provider Name (Legal Business Name): ANTHONY JERMAINE SMITH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CHALAN SAN ANTONIO SUITE 214 ISLAND EYE CENTER
TAMUNING GU
96913
US

IV. Provider business mailing address

415 CHALAN SAN ANTONIO PMB 101 166
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-5381
  • Fax: 671-647-5385
Mailing address:
  • Phone: 671-647-5381
  • Fax: 671-647-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM1185
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: