Provider Demographics
NPI:1982856423
Name:SMITH, THERESA A
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 E 34TH STREET
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4202
Mailing Address - Country:US
Mailing Address - Phone:850-913-0033
Mailing Address - Fax:
Practice Address - Street 1:329 E 34TH STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4202
Practice Address - Country:US
Practice Address - Phone:850-913-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine