Provider Demographics
NPI:1760470496
Name:SMITH, MARTIN T (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3025 MCVITTY FOREST DR
Mailing Address - Street 2:APT. 104
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3564
Mailing Address - Country:US
Mailing Address - Phone:540-777-1711
Mailing Address - Fax:540-777-1713
Practice Address - Street 1:3825 ELECTRIC RD STE C
Practice Address - Street 2:419 OFFICE CENTER
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4561
Practice Address - Country:US
Practice Address - Phone:540-777-1711
Practice Address - Fax:540-777-1713
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2011-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA50098207Q00000X
VA0102050098207N00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E05950Medicare UPIN
VA006815V29Medicare ID - Type Unspecified