Provider Demographics
NPI:1790757359
Name:SMITH, MARLO MONIQUE (MD)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:MONIQUE
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 1:1320 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-1118
Mailing Address - Country:US
Mailing Address - Phone:843-986-0900
Mailing Address - Fax:843-322-1875
Practice Address - Street 1:1320 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1118
Practice Address - Country:US
Practice Address - Phone:843-986-0900
Practice Address - Fax:843-322-1875
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19944208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics