Provider Demographics
NPI:1760624027
Name:SMITH, JOHN WADDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WADDELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 PEACOCK LN
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF GOLF
Mailing Address - State:FL
Mailing Address - Zip Code:33436-5620
Mailing Address - Country:US
Mailing Address - Phone:561-742-3742
Mailing Address - Fax:561-742-9769
Practice Address - Street 1:8645 W BOYNTON BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4415
Practice Address - Country:US
Practice Address - Phone:561-853-1634
Practice Address - Fax:561-369-8527
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 20038208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery