Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 0104000196 | VA |
NPI | 1508953860 |
---|---|
Provider Name | Dr. Mark S Smith |
First Address | Midlothian, VA 23113-4258 |
Second Address | Midlothian, VA 23113-4261 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 27/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
177764 | ANTHEM BC/BS ID (01) | VA |
541182330 | AETNA PROVIDER ID (01) | VA |