=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013117159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY SMITH O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 11/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W DEYOUNG ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62959-4437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-993-5686
-----------------------------------------------------
Fax | 618-997-6250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 904 W SPRINGFIELD RD
-----------------------------------------------------
City | TAYLORVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62568-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-287-2020
-----------------------------------------------------
Fax | 217-824-2228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-009974
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------