Provider Demographics
NPI:1023753779
Name:SMITH, MARIE BERNADINE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:BERNADINE
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 1:234 SAN REMO BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-3944
Mailing Address - Country:US
Mailing Address - Phone:954-328-0375
Mailing Address - Fax:
Practice Address - Street 1:234 SAN REMO BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-3944
Practice Address - Country:US
Practice Address - Phone:954-328-0375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017650261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care