Provider Demographics
NPI:1114313780
Name:SMOTHERS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SMOTHERS
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 1:1477 N DONAHUE DR
Mailing Address - Street 2:APT 2005
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830
Mailing Address - Country:US
Mailing Address - Phone:205-495-0453
Mailing Address - Fax:
Practice Address - Street 1:1477 N DONAHUE DR
Practice Address - Street 2:APT 2005
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830
Practice Address - Country:US
Practice Address - Phone:205-495-0453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10817390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program