Provider Demographics
NPI:1538401476
Name:SMITH, WILLIAM DOUGLAS (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DOUGLAS
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 1:806 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3300
Mailing Address - Country:US
Mailing Address - Phone:904-356-7101
Mailing Address - Fax:
Practice Address - Street 1:120 A1A N STE 101
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6626
Practice Address - Country:US
Practice Address - Phone:904-280-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1768152W00000X
TN3128152W00000X
FLOPC5458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB218681OtherMEDICARE PTAN