Provider Demographics
NPI:1093771180
Name:SMITH, WESLEY OMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:OMAR
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 1:1400 AFFLINK PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2289
Mailing Address - Country:US
Mailing Address - Phone:205-366-9740
Mailing Address - Fax:205-344-9992
Practice Address - Street 1:1780 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2136
Practice Address - Country:US
Practice Address - Phone:205-345-7351
Practice Address - Fax:205-345-8476
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5726174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529800880Medicaid
AL5100005938Medicare PIN
AL529800880Medicaid