Provider Demographics
NPI:1962682351
Name:SMITH, JUSTIN W (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:W
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 1:12340 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-8968
Mailing Address - Country:US
Mailing Address - Phone:740-941-5150
Mailing Address - Fax:
Practice Address - Street 1:12340 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-8968
Practice Address - Country:US
Practice Address - Phone:740-941-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.093541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine