Provider Demographics
NPI:1912034984
Name:SMITH, S. SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:S. SCOTT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:13691 METRO PKWY STE 420
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4349
Practice Address - Country:US
Practice Address - Phone:239-215-4064
Practice Address - Fax:239-215-4063
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2710207R00000X
FLME155336207R00000X
CO38479207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-066OtherTRICARE
TX8EW546OtherBCBS
TX75-2616977-118OtherTRICARE
TXP01443279OtherRAIL ROAD MEDICARE
TX342522501Medicaid
CO43302815Medicaid
TX75-2616977-007OtherTRICARE
COH27019Medicare UPIN
COCOAAA1688Medicare PIN
TX75-2616977-118OtherTRICARE
COCK11003Medicare PIN