Healthcare Provider Details

I. General information

NPI: 1114239092
Provider Name (Legal Business Name): JILL DENISE SMITH RADKOWIEC OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL DENISE SMITH

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E NORTH STREET
CALIFORNIA MO
65018
US

IV. Provider business mailing address

PO BOX 246
CALIFORNIA MO
65018
US

V. Phone/Fax

Practice location:
  • Phone: 573-796-2222
  • Fax: 573-796-4184
Mailing address:
  • Phone: 573-796-2222
  • Fax: 573-796-4184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2010020657
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: