Provider Demographics
NPI:1619990124
Name:SMITH, C. DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:DANIEL
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 1:2045 PEACHTREE RD NE STE 310
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1407
Mailing Address - Country:US
Mailing Address - Phone:404-445-7787
Mailing Address - Fax:404-445-8404
Practice Address - Street 1:2045 PEACHTREE RD NE STE 310
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1407
Practice Address - Country:US
Practice Address - Phone:404-445-7787
Practice Address - Fax:404-445-8404
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042730208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1450415OtherUNITED HEALTHCARE
GA588797OtherUS HEALTHCARE
GA000723533AMedicaid
GAY 19970101OtherPHCS
GA020035154OtherRAILROAD MEDICARE
GA50786OtherBCBS
GA588797OtherUS HEALTHCARE
GA202I025390Medicare PIN
GA1450415OtherUNITED HEALTHCARE