Provider Demographics
NPI:1730229170
Name:SMITH, JEFFREY TEDDY (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TEDDY
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 1:1011 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5110
Mailing Address - Country:US
Mailing Address - Phone:303-939-8021
Mailing Address - Fax:303-939-8025
Practice Address - Street 1:1011 PEARL ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5110
Practice Address - Country:US
Practice Address - Phone:303-939-8021
Practice Address - Fax:303-939-8025
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF1533Medicare ID - Type Unspecified
F1503Medicare ID - Type UnspecifiedGROUP#
U34759Medicare UPIN