Provider Demographics
NPI:1679669550
Name:SMITH, TANIYA (DO)
Entity Type:Individual
Prefix:DR
First Name:TANIYA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10075 GRAND BAY WILMER ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541
Mailing Address - Country:US
Mailing Address - Phone:251-865-1852
Mailing Address - Fax:
Practice Address - Street 1:10075 GRAND BAY WILMER ROAD
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541
Practice Address - Country:US
Practice Address - Phone:251-865-1852
Practice Address - Fax:251-865-1854
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL151869Medicaid