Provider Demographics
NPI:1992711840
Name:SMITH, BRADFORD D (OD)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:D
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 1:15 WESTERN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-7340
Mailing Address - Country:US
Mailing Address - Phone:207-623-2020
Mailing Address - Fax:207-623-1399
Practice Address - Street 1:15 WESTERN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7340
Practice Address - Country:US
Practice Address - Phone:207-623-2020
Practice Address - Fax:207-623-1399
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME092002183OtherFED BC
MEMNT692OtherHARVARD PILGRIM
ME2119511OtherAETNA
ME115000000Medicaid
MEPR92498370001OtherCIGNA
ME410019231OtherRAILROAD MEDICARE
ME092002183OtherFED BC
ME115000000Medicaid
ME0368010001Medicare NSC