Provider Demographics
NPI:1083704712
Name:SMITH, DENISE W (MD)
Entity Type:Individual
Prefix:DR
First Name:DENISE
Middle Name:W
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 1:100 MYRTLE BLVD
Mailing Address - Street 2:
Mailing Address - City:GRACEWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30812-1500
Mailing Address - Country:US
Mailing Address - Phone:706-790-2160
Mailing Address - Fax:
Practice Address - Street 1:100 MYRTLE BLVD
Practice Address - Street 2:
Practice Address - City:GRACEWOOD
Practice Address - State:GA
Practice Address - Zip Code:30812-1500
Practice Address - Country:US
Practice Address - Phone:706-790-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022643208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA37BDBXDMedicare ID - Type Unspecified
GAF12973Medicare UPIN