Provider Demographics
NPI:1760553978
Name:SMITH, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 GILBREATH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-2827
Mailing Address - Country:US
Mailing Address - Phone:205-274-8198
Mailing Address - Fax:205-274-8197
Practice Address - Street 1:150 GILBREATH DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2827
Practice Address - Country:US
Practice Address - Phone:205-274-8198
Practice Address - Fax:205-274-8197
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL9492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541387304Medicaid
AL000085124Medicaid
AL000085124Medicaid
AL541387304Medicaid