Healthcare Provider Details

I. General information

NPI: 1326119223
Provider Name (Legal Business Name): MICHEL E HANEN SMITH O.D., M..S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 12/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

IV. Provider business mailing address

4323 E LAKE ST
MINNEAPOLIS MN
55406-2307
US

V. Phone/Fax

Practice location:
  • Phone: 612-722-1003
  • Fax: 612-721-6331
Mailing address:
  • Phone: 612-722-1003
  • Fax: 612-721-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberLD1652000
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberLD1652000
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberLD1652000
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number362
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: