Provider Demographics
NPI:1417165028
Name:SMITH, GRAY ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:GRAY
Middle Name:ROBERT
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 1:2250 E HIGHWAY 50
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6052
Mailing Address - Country:US
Mailing Address - Phone:352-243-5349
Mailing Address - Fax:352-243-8358
Practice Address - Street 1:2250 E HIGHWAY 50
Practice Address - Street 2:SUITE 1
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6052
Practice Address - Country:US
Practice Address - Phone:352-243-5349
Practice Address - Fax:352-243-8358
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3661152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL880BMedicare PIN