Healthcare Provider Details

I. General information

NPI: 1801515366
Provider Name (Legal Business Name): MADISON NICOLE SMITH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 12/26/2022
Certification Date: 12/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1073 PRAY BLVD
WATERVILLE OH
43566-8712
US

IV. Provider business mailing address

1073 PRAY BLVD # 11
WATERVILLE OH
43566-8712
US

V. Phone/Fax

Practice location:
  • Phone: 567-952-2020
  • Fax:
Mailing address:
  • Phone: 567-952-2020
  • Fax: 567-952-2142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.007080
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: