Provider Demographics
NPI:1073563573
Name:SMITH, CORY W (OD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1559
Practice Address - Country:US
Practice Address - Phone:719-544-9494
Practice Address - Fax:719-230-0097
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO920713020820OtherEYE SPECIALISTS
CO02628384Medicaid
CO0452890001OtherMEDICARE DMERC
CO66441OtherANTHEM
COCO2379OtherEYEMED EYECARE
CO608439600OtherUS DEPT LABOR WORK COMP
COP00041114OtherRAILROAD MEDICARE
COSM66441OtherANTHEM BCBS
COSM66441OtherANTHEM BCBS
CO66441OtherANTHEM