Healthcare Provider Details

I. General information

NPI: 1134156144
Provider Name (Legal Business Name): CRAIG K SMALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 HERSCHEL ST
CARIBOU ME
04736-2426
US

IV. Provider business mailing address

37 HERSCHEL ST
CARIBOU ME
04736-2426
US

V. Phone/Fax

Practice location:
  • Phone: 207-496-5111
  • Fax: 207-498-6502
Mailing address:
  • Phone: 207-496-5111
  • Fax: 207-498-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT736
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPT736
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT736
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: