Provider Demographics
NPI:1124059001
Name:SMITH, MICHAEL KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
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 1:1239 GOGGIN LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-9366
Mailing Address - Country:US
Mailing Address - Phone:859-466-0755
Mailing Address - Fax:
Practice Address - Street 1:104 SMOKY WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8728
Practice Address - Country:US
Practice Address - Phone:859-236-8644
Practice Address - Fax:859-236-0523
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1556DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist