Basic Information
| Provider Information | |||||||||
| NPI: | 1891256038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3595 OLENTANGY RIVER RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432143440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145665456 | ||||||||
| FaxNumber: | 6145666902 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522736575 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2019 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.