Provider Demographics
NPI:1205095239
Name:SMITH, LEROY (COTA)
Entity type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4413 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-1501
Mailing Address - Country:US
Mailing Address - Phone:757-483-1419
Mailing Address - Fax:
Practice Address - Street 1:200 W CONSTANCE RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4413
Practice Address - Country:US
Practice Address - Phone:757-539-8744
Practice Address - Fax:757-539-8764
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1008775171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor