Healthcare Provider Details

I. General information

NPI: 1215974548
Provider Name (Legal Business Name): ELVEN CONRAD SMITH III O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 E US HIGHWAY 74 STE A
ROCKINGHAM NC
28379-7524
US

IV. Provider business mailing address

1502 E BROAD AVE STE A
ROCKINGHAM NC
28379-4908
US

V. Phone/Fax

Practice location:
  • Phone: 910-205-2020
  • Fax: 910-582-2030
Mailing address:
  • Phone: 910-997-7737
  • Fax: 910-997-7058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1267
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1267
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1182
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: