Provider Demographics
NPI:1376541292
Name:SMITH, DIANE K (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1808
Mailing Address - Country:US
Mailing Address - Phone:706-860-3001
Mailing Address - Fax:706-860-0305
Practice Address - Street 1:1220 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1808
Practice Address - Country:US
Practice Address - Phone:706-860-3001
Practice Address - Fax:706-860-0305
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023111133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00228335BMedicaid
SCG03083Medicaid
GAE15941Medicare UPIN
GA11BDKVQMedicare ID - Type Unspecified