1669792776 NPI number — MS. ALLESSA ALLISON SMITH M.D.

Table of content: MS. ALLESSA ALLISON SMITH M.D. (NPI 1669792776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669792776 NPI number — MS. ALLESSA ALLISON SMITH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
ALLESSA
Provider Middle Name:
ALLISON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ALLISON
Provider Other First Name:
ALLESSA
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1669792776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 BRENT LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-471-2221
Provider Business Mailing Address Fax Number:
850-471-2245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 BRENT LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-471-2221
Provider Business Practice Location Address Fax Number:
850-471-2245
Provider Enumeration Date:
06/11/2010

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: 207V00000X , with the licence number:  ME119638 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D12630400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012630400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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