Healthcare Provider Details

I. General information

NPI: 1437144037
Provider Name (Legal Business Name): MARK ALLEN SMITH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15821 SR 525
LANGLEY WA
98260-9780
US

IV. Provider business mailing address

15821 SR 525
LANGLEY WA
98260-9780
US

V. Phone/Fax

Practice location:
  • Phone: 360-321-4779
  • Fax: 360-321-4782
Mailing address:
  • Phone: 360-321-4779
  • Fax: 360-321-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00001519
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: