Provider Demographics
NPI:1003810581
Name:SMITH, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:1021 QUARRIER ST
Mailing Address - Street 2:STE 301
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2313
Mailing Address - Country:US
Mailing Address - Phone:304-343-4625
Mailing Address - Fax:304-343-4626
Practice Address - Street 1:416 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1456
Practice Address - Country:US
Practice Address - Phone:304-766-7141
Practice Address - Fax:304-766-7143
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA149702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0120020000Medicaid
WV0610375Medicare ID - Type Unspecified
WVC35081Medicare UPIN
WV0120020000Medicaid