Provider Demographics
NPI:1629203815
Name:SMITH, NICHOLAS ALEXANDER (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ALEXANDER
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 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-6468
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20600207Q00000X, 207QS0010X
ND14269207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120820900Medicaid