Basic Information
| Provider Information | |||||||||
| NPI: | 1023002540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMICK | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CORPORATE CENTER DRIVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7709602473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 CORPORATE CENTER DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302604180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709688888 | ||||||||
| FaxNumber: | 7709602473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 11/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT000737 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000004683D | 05 | GA | MEDICAID | 406540201 | 01 | GA | RAILROAD MEDICARE | OTHER |