Provider Demographics
NPI:1588645758
Name:BACCHI-SMITH, DONNA R
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:BACCHI-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2446
Mailing Address - Country:US
Mailing Address - Phone:910-739-3318
Mailing Address - Fax:910-671-3600
Practice Address - Street 1:400 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2446
Practice Address - Country:US
Practice Address - Phone:910-739-3318
Practice Address - Fax:910-671-3600
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242134208000000X
NC201502231208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138868808Medicaid
TX80829ZOtherHMO BLUE
NMA165OtherTRIWEST
NMS6336Medicaid
TXBB4395895OtherDEA
TX107865101Medicaid
NM68866Medicaid
TX86Z584OtherBC/BS
TXL0072811OtherDPS
TX107865100OtherFIRSTCARE COMMERCIAL
OK100008600AMedicaid
TX138868807Medicaid
NM68866OtherPRESBYTERIAN COMMERCIAL
TXL0072811OtherDPS
NMA165OtherTRIWEST
NM68866OtherPRESBYTERIAN COMMERCIAL