Provider Demographics
NPI:1275505026
Name:SMITH, MARK O'DELL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:O'DELL
Last Name:SMITH
Suffix:
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:LEWIS GALE MEDICAL CENTER
Practice Address - Street 2:1900 ELECTRIC ROAD
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-01853208600000X
VA0101-040639208600000X, 2086S0102X
SC40212208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010018919Medicaid
SCSC97127628OtherMEDICARE PIN
VA1275505026Medicaid
SC402120Medicaid
40212OtherSC LICENSE #
VA010018919Medicaid
VA1275505026Medicaid