Provider Demographics
NPI:1104868033
Name:SMITH, BRYAN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAMES
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 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8100
Mailing Address - Fax:850-862-2303
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8100
Practice Address - Fax:850-862-2303
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107850207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine