Provider Demographics
NPI:1073387221
Name:SMITH, JOHN DAVID
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 AUTUN RD
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:SC
Mailing Address - Zip Code:29670-9115
Mailing Address - Country:US
Mailing Address - Phone:864-337-8023
Mailing Address - Fax:
Practice Address - Street 1:1401 AUTUN RD
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:SC
Practice Address - Zip Code:29670-9115
Practice Address - Country:US
Practice Address - Phone:864-337-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner