Provider Demographics
NPI:1487653416
Name:SMITH, ELTON TRAVIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ELTON
Middle Name:TRAVIS
Last Name:SMITH
Suffix:JR
Gender:M
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:PO BOX 30637
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1248
Practice Address - Country:US
Practice Address - Phone:704-973-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401109207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904987Medicaid
SC18494OtherSTATE MEDICAL BOARD
NC9401109OtherSTATE MEDICAL BOARD
SC184945Medicaid
WV0104299000Medicaid