Provider Demographics
NPI:1568571263
Name:SMIDTAS, RENALDAS (MD)
Entity Type:Individual
Prefix:
First Name:RENALDAS
Middle Name:
Last Name:SMIDTAS
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 1:413 NW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052
Mailing Address - Country:US
Mailing Address - Phone:386-792-0753
Mailing Address - Fax:386-792-2412
Practice Address - Street 1:413 NW 5TH AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052
Practice Address - Country:US
Practice Address - Phone:386-792-0753
Practice Address - Fax:386-792-2412
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27984OtherBLUE CROSS BLUE SHIELD
FL378783400Medicaid
FL103986OtherAVMED
FL103986OtherAVMED
FL378783400Medicaid