Provider Demographics
NPI:1043239817
Name:SMITH, JOHNNY DWAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:DWAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2231
Mailing Address - Country:US
Mailing Address - Phone:304-472-1600
Mailing Address - Fax:304-472-6055
Practice Address - Street 1:11 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2231
Practice Address - Country:US
Practice Address - Phone:304-472-1600
Practice Address - Fax:304-472-6055
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721765OtherMOUNTAIN STATE BCBS
WVWV01672OtherHEALTH PLAN
WV3810001252Medicaid
WVP00154078OtherRAILROAD MEDICARE
WV001721766OtherBCBS
WV001721765OtherMOUNTAIN STATE BCBS
WVSM4144761Medicare PIN
WV001721766OtherBCBS