Provider Demographics
NPI:1558350561
Name:SMITH, CHRISTINE WESSELS (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:WESSELS
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:WESSELS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:405 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2101
Mailing Address - Country:US
Mailing Address - Phone:727-345-2212
Mailing Address - Fax:
Practice Address - Street 1:405 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-2101
Practice Address - Country:US
Practice Address - Phone:727-345-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065301208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288323Medicaid
G06668Medicare UPIN