Provider Demographics
NPI:1609065606
Name:SMITH, VICTOR NORDINE
Entity Type:Individual
Prefix:MRS
First Name:VICTOR
Middle Name:NORDINE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8787 SALT GRASS DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-3262
Mailing Address - Country:US
Mailing Address - Phone:850-503-6090
Mailing Address - Fax:
Practice Address - Street 1:8787 SALT GRASS DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-3262
Practice Address - Country:US
Practice Address - Phone:850-503-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690447898Medicaid
FL690437896Medicaid