Provider Demographics
NPI:1104815992
Name:SMITH, EMMETT DONALD (OD)
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:DONALD
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:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1108
Mailing Address - Country:US
Mailing Address - Phone:662-846-6641
Mailing Address - Fax:662-846-6644
Practice Address - Street 1:136 NORTH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2744
Practice Address - Country:US
Practice Address - Phone:662-846-6641
Practice Address - Fax:662-846-6644
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS546152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09957099Medicaid
MS09957099Medicaid
410000023Medicare ID - Type Unspecified
0289000001Medicare NSC