MEDICARE: DR. TIMOTHY JOHN SMITH 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	TO2464	MO

General Provider Information

NPI Number	:	1841224987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY JOHN SMITH O.D.

Provider Business Mailing Address
First Line	:	112A WESTWOODS DR
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-1181
Country	:	US
Telephone Number	:	816-781-2220
Fax Number	:	816-781-2854

Provider Business Practice Location Address
First Line	:	112A WESTWOODS DR
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-1181
Country	:	US
Telephone Number	:	816-781-2220
Fax Number	:	816-781-2854

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/08/2007

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