Provider Demographics
NPI:1003017468
Name:SMITH, RYAN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 INTERSTATE PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5625
Mailing Address - Country:US
Mailing Address - Phone:706-651-2020
Mailing Address - Fax:706-855-6674
Practice Address - Street 1:1330 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5625
Practice Address - Country:US
Practice Address - Phone:706-651-2020
Practice Address - Fax:706-855-6674
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57009416207W00000X
GA66645207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00725745OtherRAILROAD MEDICARE
OHP00748929OtherRAILROAD MEDICARE
GA202I183712OtherPTAN
OH2965260Medicaid
KY0388414Medicare PIN
OH6038332Medicare PIN
OH2965260Medicaid
OH6038334Medicare PIN
GA202I183712OtherPTAN