Provider Demographics
NPI:1861479651
Name:SMITH, MARK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:701 GREENE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2385
Mailing Address - Country:US
Mailing Address - Phone:706-722-6900
Mailing Address - Fax:706-722-5118
Practice Address - Street 1:701 GREENE ST STE 200
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2385
Practice Address - Country:US
Practice Address - Phone:706-722-6900
Practice Address - Fax:706-722-5118
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18516207RN0300X
GA037908207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC185169Medicaid
GA00871109AMedicaid
SCG548517437Medicare PIN
SC185169Medicaid
GA00871109AMedicaid