Provider Demographics
NPI:1154432938
Name:SMITH, GOLDEN THANE (OD)
Entity type:Individual
Prefix:DR
First Name:GOLDEN
Middle Name:THANE
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 1:500 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3305
Mailing Address - Country:US
Mailing Address - Phone:208-528-8643
Mailing Address - Fax:
Practice Address - Street 1:500 S UTAH AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3305
Practice Address - Country:US
Practice Address - Phone:208-528-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1040152W00000X
UT11319935-9934152W00000X
IDODP-992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U71773Medicare UPIN