Provider Demographics
NPI:1932365699
Name:SMITH, STEFAN M (OD)
Entity type:Individual
Prefix:MR
First Name:STEFAN
Middle Name:M
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 1:724 ST. LOUIS ROAD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-2032
Mailing Address - Country:US
Mailing Address - Phone:618-345-0210
Mailing Address - Fax:618-345-4770
Practice Address - Street 1:724 ST. LOUIS ROAD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-2032
Practice Address - Country:US
Practice Address - Phone:618-345-0210
Practice Address - Fax:618-345-4770
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010136152W00000X
IL046010136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010136Medicaid
IL208834Medicare PIN