1285876763 NPI number — DR. JOSHUA DE'VON SMITH MA, DPC, LPC

Table of content: DR. JOSHUA DE'VON SMITH MA, DPC, LPC (NPI 1285876763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285876763 NPI number — DR. JOSHUA DE'VON SMITH MA, DPC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
JOSHUA
Provider Middle Name:
DE'VON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MA, DPC, LPC
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:
1285876763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10632
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39505-0632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-292-2107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 29TH AVE STE 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-2843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-292-9107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2009

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: 101YM0800X , with the licence number:  2662 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00018214 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com