Provider Demographics
NPI:1861582892
Name:SMITH, S. SCOTT I (OD)
Entity type:Individual
Prefix:
First Name:S. SCOTT
Middle Name:
Last Name:SMITH
Suffix:I
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 1:5229 154 A AVE
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T5Y 2S5
Mailing Address - Country:CA
Mailing Address - Phone:780-476-6887
Mailing Address - Fax:
Practice Address - Street 1:299 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4363
Practice Address - Country:US
Practice Address - Phone:509-525-2100
Practice Address - Fax:509-522-0313
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5747270001Medicare NSC
WAU65108Medicare UPIN