Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | POR81 | FL |
N | 222Z00000X | Podiatrist | POR81 | FL |
Y | 224P00000X | Prosthetist | POR81 | FL |
NPI | 1083939789 |
---|---|
Provider Name | Mr. Herbert George Smith JR. |
First Address | Trinity, FL 34655-1715 |
Second Address | Trinity, FL 34655-1715 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2010 |
Last Update Date | 07/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
M000M | BCBS (01) | FL |