Provider Demographics
NPI:1689749418
Name:SMITH, HOLLY GWEN (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:GWEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6115 PARK SOUTH DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3269
Mailing Address - Country:US
Mailing Address - Phone:704-944-8388
Mailing Address - Fax:704-944-8389
Practice Address - Street 1:6488 WEDDINGTON-MONROE RD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:NC
Practice Address - Zip Code:28104-6277
Practice Address - Country:US
Practice Address - Phone:704-384-8460
Practice Address - Fax:704-384-1018
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC2005-00116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F41343Medicare UPIN