Provider Demographics
NPI:1104828318
Name:SMUCKLER, DAVID T (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:T
Last Name:SMUCKLER
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 1:21 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1133
Mailing Address - Country:US
Mailing Address - Phone:321-841-6600
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:21 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1133
Practice Address - Country:US
Practice Address - Phone:321-841-6600
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050892174400000X
FLME50892207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064254100Medicaid
FL064254100Medicaid
FL04090XMedicare PIN
FL04090YMedicare PIN