=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134364953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LYNN SMOOT O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2008
-----------------------------------------------------
Last Update Date | 05/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 K ST
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-675-4199
-----------------------------------------------------
Fax | 812-675-0301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 K ST
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-675-4199
-----------------------------------------------------
Fax | 812-675-0301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18003555A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------