Provider Demographics
NPI:1326074758
Name:PAULETTE A SMART MD PA
Entity Type:Organization
Organization Name:PAULETTE A SMART MD PA
Other - Org Name:PAULETTE ANDREA SMART MD PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMART - MACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-858-1371
Mailing Address - Street 1:PO BOX 561405
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32856-1405
Mailing Address - Country:US
Mailing Address - Phone:407-858-1371
Mailing Address - Fax:407-855-0762
Practice Address - Street 1:25 W CRYSTAL LAKE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4475
Practice Address - Country:US
Practice Address - Phone:407-858-1371
Practice Address - Fax:407-855-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2010-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72680208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252661100Medicaid
FL252661100Medicaid
G34210Medicare UPIN