Provider Demographics
NPI:1841419058
Name:SMITH, CHARLES LEE (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 RED RD STE 501
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6015
Mailing Address - Country:US
Mailing Address - Phone:954-947-3290
Mailing Address - Fax:866-572-2146
Practice Address - Street 1:3600 RED RD STE 501
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025
Practice Address - Country:US
Practice Address - Phone:954-947-3290
Practice Address - Fax:866-572-2146
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS153672084A0401X
WV832208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV832OtherSTATE LICENSE
FLOS15367Other1841419058