Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | MD0000012502 | TN |
N | 111NI0900X | Internist | MD0000012502 | TN |
Y | 207RA0201X | Internist - Allergy & Immunology | MD0000012502 | TN |
NPI | 1972771012 |
---|---|
Provider Name | Dr. John Kelly Smith |
First Address | Mountain Home, TN 37684-0699 |
Second Address | Johnson City, TN 37604-6056 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2008 |
Last Update Date | 05/11/2010 |