Provider Demographics
NPI:1215089230
Name:DRS STEVEN AND BRENDA SMOKE OD PC
Entity type:Organization
Organization Name:DRS STEVEN AND BRENDA SMOKE OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMOKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:269-469-6331
Mailing Address - Street 1:18301 US HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:NEW BUFFALO
Mailing Address - State:MI
Mailing Address - Zip Code:49117-8848
Mailing Address - Country:US
Mailing Address - Phone:269-469-6331
Mailing Address - Fax:269-469-6848
Practice Address - Street 1:18301 US HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:NEW BUFFALO
Practice Address - State:MI
Practice Address - Zip Code:49117-8848
Practice Address - Country:US
Practice Address - Phone:269-469-6331
Practice Address - Fax:269-469-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI04901003315152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A10020OtherBCBS GROUP PIN
MI0P18480OtherPTAN
MI0P18480OtherPTAN
MI0P18480Medicare PIN
MI0238080003Medicare NSC