Provider Demographics
NPI:1306998919
Name:SMOKE, BRENDA DANI (OD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:DANI
Last Name:SMOKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E FRONT ST STE A
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1403
Mailing Address - Country:US
Mailing Address - Phone:269-695-3434
Mailing Address - Fax:269-695-2656
Practice Address - Street 1:400 E FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1403
Practice Address - Country:US
Practice Address - Phone:269-695-3434
Practice Address - Fax:269-695-2656
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003315152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP88602OtherBLUE CARE NETWORK
MI003740A3315OtherVSP PROVIDER
MIP18480002Medicare ID - Type UnspecifiedMEMBER NUMBER
MI003740A3315OtherVSP PROVIDER
MIP00261277Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MIU18501Medicare UPIN
MIP18510002Medicare ID - Type UnspecifiedMEMBER NUMBER