Basic Information
| Provider Information | |||||||||
| NPI: | 1063908929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KORA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469920549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605699550 | ||||||||
| FaxNumber: | 2605690760 | ||||||||
| Practice Location | |||||||||
| Address1: | 5319 S EMERSON AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462371969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177838700 | ||||||||
| FaxNumber: | 3177835987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2018 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18004115 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 300017948 | 05 | IN | MEDICAID |