Provider Demographics
NPI:1427136662
Name:SMITH, KATHRYN L (OD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:L
Last Name:SMITH
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:13080 GRAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5519
Practice Address - Country:US
Practice Address - Phone:317-575-1133
Practice Address - Fax:317-575-3615
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003431152W00000X
IN18003431A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1943014Medicare PIN
IN894060DDMedicare PIN