Provider Demographics
NPI:1104906759
Name:OLD, TAMARA SMITH (OD)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:SMITH
Last Name:OLD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:TAMARA
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4874 SPARKS BLVD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-8206
Mailing Address - Country:US
Mailing Address - Phone:775-358-1317
Mailing Address - Fax:775-355-7522
Practice Address - Street 1:4874 SPARKS BLVD
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-8206
Practice Address - Country:US
Practice Address - Phone:775-358-1317
Practice Address - Fax:775-355-7522
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100563OtherMEDICARE ID-PIN