Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 0101-040639 | VA |
N | 208600000X | Surgeon | 0101-040639 | VA |
N | 208200000X | Surgeon | 2018-01853 | NC |
N | 208600000X | Surgeon | 2018-01853 | NC |
Y | 208200000X | Surgeon | 40212 | SC |
Y | 208600000X | Surgeon | 40212 | SC |
N | 2086S0102X | Surgical Critical Care | 0101-040639 | VA |
N | 2086S0102X | Surgical Critical Care | 40212 | SC |
NPI | 1275505026 |
---|---|
Provider Name | Mark O Smith |
First Address | Atlanta, GA 30374-3070 |
Second Address | Spartanburg, SC 29307-1069 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2006 |
Last Update Date | 13/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
010018919 | (05) | VA |
013038C19 | (02) | |
1275505026 | (05) | VA |
40212 | SC LICENSE # (01) | |
402120 | (05) | SC |
D80377 | (02) | VA |
SC97127628 | MEDICARE PIN (01) | SC |