Healthcare Provider Details

I. General information

NPI: 1487655437
Provider Name (Legal Business Name): TONY SHAWN SMITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 PARIS RD
MAYFIELD KY
42066-4989
US

IV. Provider business mailing address

1225 PARIS RD
MAYFIELD KY
42066-4989
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-2020
  • Fax: 270-247-8652
Mailing address:
  • Phone: 270-251-2020
  • Fax: 270-247-8652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1391DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: