Provider Demographics
NPI:1275581704
Name:SMITH, J D (DPM)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 ROSA LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1769
Mailing Address - Country:US
Mailing Address - Phone:256-764-1806
Mailing Address - Fax:256-760-8442
Practice Address - Street 1:202 ROSA LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1769
Practice Address - Country:US
Practice Address - Phone:256-764-1806
Practice Address - Fax:256-760-8442
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL212213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51017836OtherBCBS PROVIDER
480002775OtherMEDICARE RAILROAD PTAN
1992977102OtherMEDICARE GROUP NUMBER
AL51017836OtherBCBS PROVIDER
480002775OtherMEDICARE RAILROAD PTAN