1154339687 NPI number — KEITH SMITHSON OD

Table of content: KEITH SMITHSON OD (NPI 1154339687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154339687 NPI number — KEITH SMITHSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITHSON
Provider First Name:
KEITH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1154339687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7263E ARLINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLS CHURCH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22042-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-573-1200
Provider Business Mailing Address Fax Number:
703-573-1250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11656 PLAZA AMERICA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20190-4767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-467-9080
Provider Business Practice Location Address Fax Number:
703-467-9082
Provider Enumeration Date:
08/03/2006

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: 152W00000X , with the licence number:  0618001041 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 383934 . This is a "ANTHEM BCBS/RESTON" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 383935 . This is a "ANTHEM BCBS/ALEXANDRIA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009232231 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2663321 . This is a "AETNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7671300 . This is a "AETNA PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9314-0007 . This is a "BCBS/CAREFIRST" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 295571 . This is a "MAMSI/ALLIANCE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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