Basic Information
| Provider Information | |||||||||
| NPI: | 1508868464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 SAN MARCO BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9042619353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 S 18TH ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320341902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042618787 | ||||||||
| FaxNumber: | 9042619353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | ME66525 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200029264 | 01 | FL | RAILROAD MEDICARE | OTHER | 253374000 | 05 | FL | MEDICAID |