Healthcare Provider Details

I. General information

NPI: 1396758017
Provider Name (Legal Business Name): GREGORY MICHAEL SMITH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE NAVAL MEDICAL CLINIC QUANTICO
QUANTICO VA
22134
US

IV. Provider business mailing address

1 HICKORY RIDGE DR
FREDERICKSBURG VA
22405-1402
US

V. Phone/Fax

Practice location:
  • Phone: 703-784-1634
  • Fax: 703-784-1635
Mailing address:
  • Phone: 215-850-7892
  • Fax: 703-784-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001601
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: