Provider Demographics
NPI:1346347655
Name:SMITH, BRENT ELLIOT (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ELLIOT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 WESTHAMPTON STA
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3330
Mailing Address - Country:US
Mailing Address - Phone:804-287-4200
Mailing Address - Fax:
Practice Address - Street 1:2015 WATERSIDE RD
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1265
Practice Address - Country:US
Practice Address - Phone:804-733-7390
Practice Address - Fax:804-733-7390
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033096207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010138078Medicaid
C35695Medicare UPIN
VA010138078Medicaid