Provider Demographics
NPI:1639114895
Name:SMITH, JOHN CONNOR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CONNOR
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:303 SMITH STREET
Mailing Address - Street 2:CLARK-HOLDER CLINIC, P.A.
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-812-4091
Practice Address - Street 1:303 SMITH STREET
Practice Address - Street 2:CLARK-HOLDER CLINIC, P.A.
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-812-4091
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA27916208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D42249Medicare UPIN