Healthcare Provider Details

I. General information

NPI: 1003011446
Provider Name (Legal Business Name): BAXTER J. SMITH JR., OD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 FAIRVIEW RD STE 300
CHARLOTTE NC
28210-0202
US

IV. Provider business mailing address

100 CROSSING BLVD STE 300
FRAMINGHAM MA
01702-5555
US

V. Phone/Fax

Practice location:
  • Phone: 888-964-6681
  • Fax: 888-662-0859
Mailing address:
  • Phone: 888-964-6681
  • Fax: 339-686-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number858
License Number StateNC

VIII. Authorized Official

Name: DR. BAXTER J. SMITH JR.
Title or Position: PRESIDENT
Credential: OD
Phone: 857-255-0486