Provider Demographics
NPI:1053628271
Name:SMITH, MARK THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:592 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1707
Mailing Address - Country:US
Mailing Address - Phone:731-352-2020
Mailing Address - Fax:731-352-3314
Practice Address - Street 1:592 MAIN ST N
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1707
Practice Address - Country:US
Practice Address - Phone:731-352-2020
Practice Address - Fax:731-352-3314
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist