Provider Demographics
NPI:1659392108
Name:SMITH, JUANITA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-7040
Mailing Address - Fax:757-446-7049
Practice Address - Street 1:825 FAIRFAX AVE STE 201
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-7040
Practice Address - Fax:757-446-7049
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258839207RG0300X
DEC1-0008055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE020764B86Medicare PIN
I69268Medicare UPIN
DEP00375508OtherRAILROAD MEDICARE
DE1659392108Medicaid
DEC1-0008055OtherPROFESSIONAL LICENSE
DE438958OtherCOVENTRY HEALTH CARE
DE020764B86Medicare PIN
DE522011HOSOtherBCBS OF DELAWARE-HOSPITAL
I69268Medicare UPIN