Provider Demographics
NPI:1265491294
Name:SMITH, DANIEL J (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-3503
Mailing Address - Country:US
Mailing Address - Phone:770-714-6056
Mailing Address - Fax:
Practice Address - Street 1:747 S HILL ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4830
Practice Address - Country:US
Practice Address - Phone:770-228-5407
Practice Address - Fax:770-227-1430
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113417163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00426911OtherRAILROAD MEDICARE
GA00077466GMedicaid
GAP00428789OtherRAILROAD MEDICARE
GA000777466FMedicaid
GA50BBKNZMedicare PIN
P00426911OtherRAILROAD MEDICARE
GAS50163Medicare UPIN