Provider Demographics
NPI:1629041991
Name:SMITH, SCOTT W (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 403208
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3208
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:3301 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2329
Practice Address - Country:US
Practice Address - Phone:305-743-5533
Practice Address - Fax:305-289-0630
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 7084207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57215OtherBCBS
G14200Medicare UPIN
FL57215IMedicare ID - Type Unspecified