Provider Demographics
NPI:1114937463
Name:SMITH-VANIZ, GEORGE T (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:SMITH-VANIZ
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 1:1860 CHADWICK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3465
Mailing Address - Country:US
Mailing Address - Phone:601-376-2115
Mailing Address - Fax:601-376-2114
Practice Address - Street 1:1860 CHADWICK DR STE 102
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3465
Practice Address - Country:US
Practice Address - Phone:601-376-2115
Practice Address - Fax:601-376-2114
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06467207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016278Medicaid
MS110001179Medicare PIN
MSB30273Medicare UPIN