Provider Demographics
NPI:1558416214
Name:SMITH, GEORGE JAY WALKER SR (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JAY WALKER
Last Name:SMITH
Suffix:SR
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 1:160 ALLEN ST
Mailing Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER - PATHOLOGY LAB
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:802-747-1789
Mailing Address - Fax:802-747-6525
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:RUTLAND REGIONAL MEDICAL CENTER - PATHOLOGY LAB
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4560
Practice Address - Country:US
Practice Address - Phone:802-747-1789
Practice Address - Fax:802-747-6525
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0009681207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0048280OtherBLUE SHIELD VT
VTOVN2023Medicaid
VTOVN2023Medicaid
VT0048280OtherBLUE SHIELD VT