Provider Demographics
NPI:1508953860
Name:SMITH, MARK S (DC PC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC PC
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Mailing Address - Street 1:13354 MIDLOTHIAN TPKE
Mailing Address - Street 2:STE 100
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4258
Mailing Address - Country:US
Mailing Address - Phone:804-744-5489
Mailing Address - Fax:
Practice Address - Street 1:13549 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4261
Practice Address - Country:US
Practice Address - Phone:804-897-9194
Practice Address - Fax:804-794-3734
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0104000196111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA177764OtherANTHEM BC/BS ID
VA541182330OtherAETNA PROVIDER ID
VA541182330OtherAETNA PROVIDER ID