Provider Demographics
NPI:1497429815
Name:SMITH, LEVI JACOB (OD)
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:JACOB
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 1:400 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1408
Mailing Address - Country:US
Mailing Address - Phone:320-589-1313
Mailing Address - Fax:
Practice Address - Street 1:400 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1408
Practice Address - Country:US
Practice Address - Phone:320-589-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009435152W00000X
MN3788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist