Provider Demographics
NPI:1518945179
Name:SMITH, KEVIN L (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
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 1:4117 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:813-207-8954
Practice Address - Street 1:4117 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629
Practice Address - Country:US
Practice Address - Phone:813-207-8984
Practice Address - Fax:813-207-8954
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3456152W00000X
FLOPC3456332H00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11221087OtherCAQH
FL582528891OtherIRS
FLAJ611OtherGROUP MEDICARE PTAN
FL620814201Medicaid
FL582528891OtherIRS
U93390Medicare UPIN