Provider Demographics
NPI:1639272537
Name:SMITH, STANLEY T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:T
Last Name:SMITH
Suffix:JR
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 1:63 CONIFER CIR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4508
Mailing Address - Country:US
Mailing Address - Phone:706-733-0548
Mailing Address - Fax:
Practice Address - Street 1:465 N BELAIR RD STE 2B
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3190
Practice Address - Country:US
Practice Address - Phone:706-774-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF41134Medicare UPIN
GA11BDJGNMedicare ID - Type Unspecified