Provider Demographics
NPI:1881669422
Name:SMITH, MARK ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4620 N HABANA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7107
Mailing Address - Country:US
Mailing Address - Phone:813-875-9362
Mailing Address - Fax:813-876-7055
Practice Address - Street 1:4620 N HABANA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7107
Practice Address - Country:US
Practice Address - Phone:813-875-9362
Practice Address - Fax:813-876-7055
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2010-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME38809207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL161540500OtherUS DEPT OF LABOR
FL210647OtherAVMED
FL290005684OtherRAILROAD MEDICARE
FL067400100Medicaid
FL30549OtherBCBS
FL33614A003OtherCHAMPUS
FL30549ZMedicare ID - Type Unspecified
FL210647OtherAVMED