Provider Demographics
NPI:1578556619
Name:SMITH, WENDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:
Last Name:SMITH
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 1:5294 ADAMS ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2628
Mailing Address - Country:US
Mailing Address - Phone:770-787-5600
Mailing Address - Fax:
Practice Address - Street 1:5294 ADAMS ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2628
Practice Address - Country:US
Practice Address - Phone:770-787-5600
Practice Address - Fax:770-787-5601
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000269442LMedicaid
GA613634OtherSTATE HEALTH
D42147Medicare UPIN
GA000269442LMedicaid