Provider Demographics
NPI:1497347546
Name:SMART, DIPTIBEN
Entity Type:Individual
Prefix:DR
First Name:DIPTIBEN
Middle Name:
Last Name:SMART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 ANCONA AVE
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-5413
Mailing Address - Country:US
Mailing Address - Phone:321-695-4422
Mailing Address - Fax:386-218-4913
Practice Address - Street 1:2413 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7964
Practice Address - Country:US
Practice Address - Phone:386-218-4993
Practice Address - Fax:386-218-4913
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist