Basic Information
| Provider Information | |||||||||
| NPI: | 1083786644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | GUY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1208 BEALL LN | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975021573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416645151 | ||||||||
| FaxNumber: | 8777729433 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417731414 | ||||||||
| FaxNumber: | 5417735613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 03/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1461ATI | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 058446 | 05 | OR | MEDICAID |