Provider Demographics
NPI:1235121724
Name:SMITH, MATTHEW GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GREGORY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:530 TYRONE BLVD N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-7125
Mailing Address - Country:US
Mailing Address - Phone:727-823-3022
Mailing Address - Fax:727-343-6755
Practice Address - Street 1:530 TYRONE BLVD N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-7125
Practice Address - Country:US
Practice Address - Phone:727-823-3022
Practice Address - Fax:727-343-6755
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME90555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3702ZMedicare PIN