Provider Demographics
NPI:1659930279
Name:GUOBADIA, SMART
Entity Type:Individual
Prefix:MR
First Name:SMART
Middle Name:
Last Name:GUOBADIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 MCKENDREE CHURCH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6000
Mailing Address - Country:US
Mailing Address - Phone:470-338-1671
Mailing Address - Fax:888-541-3996
Practice Address - Street 1:1174 MCKENDREE CHURCH RD STE 100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6000
Practice Address - Country:US
Practice Address - Phone:470-338-1671
Practice Address - Fax:888-541-3996
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-1663251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003216332BMedicaid
GA003216332AMedicaid