Provider Demographics
NPI:1003828179
Name:SMITH, EDWIN A (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:A
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 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:5445 MERIDIAN MARKS RD NE
Practice Address - Street 2:SUITE 420
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:404-252-5206
Practice Address - Fax:404-252-1268
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0342462088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ34246Medicaid
GA000694999BMedicaid
GA340014353OtherRAILROAD MEDICARE
GA340014353OtherRAILROAD MEDICARE
SCQ34246Medicaid
GA340014353OtherRAILROAD MEDICARE