Provider Demographics
NPI:1053302513
Name:SMITH, MICHAEL Q (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:Q
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 1:4379 RIDGEWOOD CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8323
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:703-680-7953
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044418207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00743S66Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO.