Provider Demographics
NPI:1710958681
Name:SMITH, EDDIE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 CARROLLTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:VA
Mailing Address - Zip Code:23314-3214
Mailing Address - Country:US
Mailing Address - Phone:757-238-8751
Mailing Address - Fax:757-238-8750
Practice Address - Street 1:13609 CARROLLTON BLVD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3214
Practice Address - Country:US
Practice Address - Phone:757-238-8751
Practice Address - Fax:757-238-8750
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0574NOtherNC BC BS
VA2180466OtherUHC/MAMSI
NC790574NMedicaid
VAPAROtherAETNA
VAPAROtherUSA MANAGED CARE
VA005612748Medicaid
VA005615577Medicaid
VAPAROtherMULTIPLAN
VAPAROtherFIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY
VA-002 -003OtherTRICARE/CHAMPUS
VAPAROtherCIGNA
VA434846OtherANTHEM BC/BS HEALTHKEEPER
VA21017OtherSENTARA/OPTIMA
VAPAROtherVIRGINIA HEALTH NETWORK
VAPAROtherCORVEL/CORCARE
VAPAROtherVIRGINIA PREMIER HEALTH
VAPAROtherCORVEL/CORCARE
VA434846OtherANTHEM BC/BS HEALTHKEEPER
VAPAROtherVIRGINIA PREMIER HEALTH
VA005615577Medicaid