Healthcare Provider Details

I. General information

NPI: 1184690877
Provider Name (Legal Business Name): PHILIP L SMITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N MAIN AVE
SAN ANTONIO TX
78212-4701
US

IV. Provider business mailing address

1100 N MAIN AVE
SAN ANTONIO TX
78212-4701
US

V. Phone/Fax

Practice location:
  • Phone: 210-222-2154
  • Fax: 210-227-6056
Mailing address:
  • Phone: 210-222-2154
  • Fax: 210-227-6056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number04549TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: