Provider Demographics
NPI:1366548059
Name:BRADFORD D SMITH
Entity type:Organization
Organization Name:BRADFORD D SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-623-2020
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT-693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
09Z002183OtherFED/BC
MEMNT 692OtherHARVARD PILGRIM
2119511OtherAETNA
MEPR92498370001OtherCIGNA
09Z002183OtherFED/BC
SMMM0760Medicare ID - Type Unspecified