MEDICARE: DR. CODY SMOUSE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1704	SC

General Provider Information

NPI Number	:	1770845489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CODY SMOUSE O.D.

Provider Business Mailing Address
First Line	:	894 WYNFORD CT
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-9785
Country	:	US
Telephone Number	:	724-689-5073
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 RUTLEDGE AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29401-1333
Country	:	US
Telephone Number	:	843-577-2674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2012
Last Update Date	:	01/07/2015

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