Provider Demographics
NPI:1043211204
Name:SMITH, PAULA RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6089
Mailing Address - Country:US
Mailing Address - Phone:423-431-1810
Mailing Address - Fax:423-431-1811
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 24
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
Practice Address - Country:US
Practice Address - Phone:423-431-1810
Practice Address - Fax:423-431-1811
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102663207Q00000X
TN47736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100240050Medicaid
TN1525800Medicaid
VA1043211204Medicaid
TNP00984680OtherRR MEDICARE
VAH32726Medicare UPIN
VA001254B78Medicare ID - Type Unspecified
TN103I085064Medicare PIN