Healthcare Provider Details

I. General information

NPI: 1437329190
Provider Name (Legal Business Name): JUSTIN BRADLEY SMITH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2008
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BAKER AVE
CONCORD MA
01742-2129
US

IV. Provider business mailing address

330 BAKER AVE
CONCORD MA
01742-2129
US

V. Phone/Fax

Practice location:
  • Phone: 978-287-9494
  • Fax: 978-287-9404
Mailing address:
  • Phone: 978-287-9494
  • Fax: 978-287-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4654
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4654
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4654
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: