Provider Demographics
NPI:1083786644
Name:SMITH, DOUGLAS GUY (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GUY
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 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:877-772-9433
Practice Address - Street 1:585 MURPHY RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8128
Practice Address - Country:US
Practice Address - Phone:541-773-1414
Practice Address - Fax:541-773-5613
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1461ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR058446Medicaid
OR058446Medicaid
ORT68146Medicare UPIN
OR0377410001Medicare NSC