Provider Demographics
NPI:1598767857
Name:MASTERMAN-SMITH, CARYN J (DO)
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:J
Last Name:MASTERMAN-SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:125 CHURCH ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4770
Practice Address - Country:US
Practice Address - Phone:912-538-8484
Practice Address - Fax:912-538-8665
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8651208000000X
GA63712208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA880935875AMedicaid
FL266853000Medicaid
GA27-0547617OtherTAX ID
BS7794628OtherDEA