Provider Demographics
NPI:1023275468
Name:KEVIN SMITH OD AND ASSOCIATES INC
Entity type:Organization
Organization Name:KEVIN SMITH OD AND ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-207-8984
Mailing Address - Street 1:4117 HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5749
Mailing Address - Country:US
Mailing Address - Phone:813-207-8984
Mailing Address - Fax:
Practice Address - Street 1:4117 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5749
Practice Address - Country:US
Practice Address - Phone:813-207-8984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC3456OtherSTATE OF FLORIDA
FL620814200Medicaid
FL5929060001OtherPTAN
FLOPC3456OtherSTATE OF FLORIDA
FL620814200Medicaid