Provider Demographics
NPI:1790700938
Name:SMITH, CONNIE (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2941
Mailing Address - Country:US
Mailing Address - Phone:706-737-0183
Mailing Address - Fax:706-737-7915
Practice Address - Street 1:3207 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2941
Practice Address - Country:US
Practice Address - Phone:706-737-0183
Practice Address - Fax:706-737-7915
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00238367HMedicaid
GA00238367GMedicaid
GA08CBBJLMedicare ID - Type UnspecifiedMEDICARE
GA00238367GMedicaid