Provider Demographics
NPI:1235542093
Name:SMITH, ROBERT (IDMT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 AUTH RD APT 638
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4363
Mailing Address - Country:US
Mailing Address - Phone:205-213-7044
Mailing Address - Fax:
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:ANDREWS AIR FORCE BASE
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:240-857-5911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians