Provider Demographics
NPI:1396795449
Name:SMITH, SCOTT GALEN (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:GALEN
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 1:2116 SHEFFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-2732
Mailing Address - Country:US
Mailing Address - Phone:724-378-2880
Mailing Address - Fax:724-378-0450
Practice Address - Street 1:2116 SHEFFIELD RD
Practice Address - Street 2:
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-2732
Practice Address - Country:US
Practice Address - Phone:724-378-2880
Practice Address - Fax:724-378-0450
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001092152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012771190004Medicaid
U05764Medicare UPIN
PA631337Medicare PIN
PA0676560001Medicare NSC