Provider Demographics
NPI:1770639767
Name:SMITH, GLADYS REA (CERTIFIED MASTECTOMY)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:REA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CERTIFIED MASTECTOMY
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:
Other - Last Name:REA SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 S PICKETT ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7206
Mailing Address - Country:US
Mailing Address - Phone:703-461-7534
Mailing Address - Fax:703-461-7534
Practice Address - Street 1:50 S PICKETT ST
Practice Address - Street 2:SUITE 210
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7206
Practice Address - Country:US
Practice Address - Phone:703-461-7534
Practice Address - Fax:703-461-7534
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC18127335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0668390001Medicare ID - Type Unspecified