1255369732 NPI number — DR. STEPHANIE J SMITH MD

Table of content: DR. STEPHANIE J SMITH MD (NPI 1255369732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255369732 NPI number — DR. STEPHANIE J SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
STEPHANIE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255369732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 551420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33355-1420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
954-839-2569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 JESSE JEWELL PKWY SE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-297-7277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  039472 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00824271A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000824271B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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