Provider Demographics
NPI:1669465670
Name:SMITH, RONNIE R (M D)
Entity Type:Individual
Prefix:DR
First Name:RONNIE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:200 MAPLE DRIVE
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1367
Mailing Address - Country:US
Mailing Address - Phone:912-537-9851
Mailing Address - Fax:912-537-9843
Practice Address - Street 1:200 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8907
Practice Address - Country:US
Practice Address - Phone:912-537-9851
Practice Address - Fax:912-537-9843
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017886207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000144867AMedicaid
GA204764OtherSTATE HEALTH BENEFITS
GA408113438OtherRAILROAD MEDICARE
GA581356947OtherPRACTICE FEDERAL TAX ID
GA000144867AMedicaid