Healthcare Provider Details

I. General information

NPI: 1104815992
Provider Name (Legal Business Name): EMMETT DONALD SMITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 NORTH ST
CLEVELAND MS
38732-2744
US

IV. Provider business mailing address

PO BOX 1108
CLEVELAND MS
38732-1108
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-6641
  • Fax: 662-846-6644
Mailing address:
  • Phone: 662-846-6641
  • Fax: 662-846-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number546
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: