Provider Demographics
NPI:1477079143
Name:SMITH, LEON HOWARD I
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:HOWARD
Last Name:SMITH
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10460 CHRISTANNA HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-4506
Mailing Address - Country:US
Mailing Address - Phone:804-586-7532
Mailing Address - Fax:
Practice Address - Street 1:10460 CHRISTANNA HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868-4506
Practice Address - Country:US
Practice Address - Phone:804-586-7532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT69508651172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver