Provider Demographics
NPI:1790045094
Name:SMITH, BRYAN WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:WESLEY
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 1:1409 DEVINE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-3902
Mailing Address - Country:US
Mailing Address - Phone:803-777-2913
Mailing Address - Fax:803-777-0126
Practice Address - Street 1:1409 DEVINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-3902
Practice Address - Country:US
Practice Address - Phone:803-777-2913
Practice Address - Fax:803-777-0126
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC345862080S0010X
NC397452080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7977421Medicaid
NC7977421Medicaid