=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417195405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EOT-ADS LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2009
-----------------------------------------------------
Last Update Date | 01/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 SE LOOP 338
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79762-9703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-367-7241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5757 COLORADO AVE
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79762-9410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-367-7241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALAN DANIEL SMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 432-617-0036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | J1042
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------