Basic Information
| Provider Information | |||||||||
| NPI: | 1427101245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMALLWOOD | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
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| Credential: | OPTICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3469 N MAYO TRL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415013265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3469 N MAYO TRL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415013265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 509 | KY | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 52000106 | 05 | KY | MEDICAID |