Provider Demographics
NPI:1225276553
Name:SMITH, FREDERICK RAYMOND JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:RAYMOND
Last Name:SMITH
Suffix:JR
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 1:3945 PINETOP BLVD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3636
Mailing Address - Country:US
Mailing Address - Phone:321-267-5396
Mailing Address - Fax:
Practice Address - Street 1:3945 PINETOP BLVD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3636
Practice Address - Country:US
Practice Address - Phone:321-267-5396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0030862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048420200Medicaid
FLD64623Medicare UPIN
FL93839Medicare PIN