Provider Demographics
NPI:1558329763
Name:SMITH, ELIZABETH THERESA (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:THERESA
Last Name:SMITH
Suffix:
Gender:F
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 281
Mailing Address - Street 2:
Mailing Address - City:OLD FIELDS
Mailing Address - State:WV
Mailing Address - Zip Code:26845-0281
Mailing Address - Country:US
Mailing Address - Phone:304-538-6634
Mailing Address - Fax:
Practice Address - Street 1:17978 SR 55
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:WV
Practice Address - Zip Code:26801
Practice Address - Country:US
Practice Address - Phone:304-897-5915
Practice Address - Fax:304-897-6216
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16642207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1558329763OtherNPI
WV1809357000Medicaid
WV1809357000Medicaid
WV9189782Medicare PIN