Provider Demographics
NPI:1225127129
Name:SMITH, TAMARA SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:SUSAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:14535 JOHN MARSHALL HWY, SUITE 212
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-4025
Practice Address - Country:US
Practice Address - Phone:571-248-0245
Practice Address - Fax:571-248-0241
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243112207R00000X, 207K00000X
WV21653207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016040950001Medicaid
VA1225127129Medicaid