Provider Demographics
NPI:1427101245
Name:SMALLWOOD, JAMES (OPTICIAN)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3469 N MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3265
Mailing Address - Country:US
Mailing Address - Phone:606-437-7702
Mailing Address - Fax:606-437-2307
Practice Address - Street 1:3469 N MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3265
Practice Address - Country:US
Practice Address - Phone:606-437-7702
Practice Address - Fax:606-437-2307
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY509156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52000106Medicaid