Provider Demographics
NPI:1184685976
Name:SMITH, THOMAS LARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LARRY
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 1:2200 OPITZ BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3321
Mailing Address - Country:US
Mailing Address - Phone:703-492-4140
Mailing Address - Fax:703-991-8104
Practice Address - Street 1:2200 OPITZ BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3321
Practice Address - Country:US
Practice Address - Phone:703-492-4140
Practice Address - Fax:703-991-8104
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052153174400000X
VA101052153207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5900409Medicaid
VA5900409Medicaid
VAVVF482AMedicare PIN