Provider Demographics
NPI:1790822450
Name:SMITH, MARTHA GIBSON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:GIBSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1132 GREENWOOD CLFS
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2821
Mailing Address - Country:US
Mailing Address - Phone:704-376-6577
Mailing Address - Fax:704-335-8941
Practice Address - Street 1:1132 GREENWOOD CLFS
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2821
Practice Address - Country:US
Practice Address - Phone:704-376-6577
Practice Address - Fax:704-335-8941
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC398862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCBS2641238Medicare UPIN
NC2168494GMedicare ID - Type UnspecifiedMEDICARE ID #