Provider Demographics
NPI:1497974273
Name:SMETKA, VLASTIMIL (MD)
Entity Type:Individual
Prefix:
First Name:VLASTIMIL
Middle Name:
Last Name:SMETKA
Suffix:
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 1:501 ROBERTSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2787
Mailing Address - Country:US
Mailing Address - Phone:843-782-2737
Mailing Address - Fax:866-225-7578
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-782-2737
Practice Address - Fax:866-225-7578
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29413207Q00000X
SC29413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC294130Medicaid
SCP00851427OtherRR MEDICARE PTAN
57-0359174OtherTAX ID
57-0359174OtherTAX ID
SCP00851427OtherRR MEDICARE PTAN