Basic Information
| Provider Information | |||||||||
| NPI: | 1093927451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704280462 | ||||||||
| FaxNumber: | 7704278001 | ||||||||
| Practice Location | |||||||||
| Address1: | 5147 N 9TH AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504949000 | ||||||||
| FaxNumber: | 8504161911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2007 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | 90208 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | ME116493 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | HK287Z | 01 | FL | MCR | OTHER | 0090481-00 | 05 | FL | MEDICAID |