Provider Demographics
NPI:1528242559
Name:JOHN W L SMITH OD
Entity type:Organization
Organization Name:JOHN W L SMITH OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTESON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:803-279-5277
Mailing Address - Street 1:531 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3701
Mailing Address - Country:US
Mailing Address - Phone:803-279-5277
Mailing Address - Fax:803-279-0699
Practice Address - Street 1:531 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3701
Practice Address - Country:US
Practice Address - Phone:803-279-5277
Practice Address - Fax:803-279-0699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0658800001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
T24615Medicare UPIN
0658800001Medicare NSC
T246157127Medicare PIN