Provider Demographics
NPI:1245541994
Name:JOHN, SMITHA MARY (MD,)
Entity type:Individual
Prefix:DR
First Name:SMITHA
Middle Name:MARY
Last Name:JOHN
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:DR
Other - First Name:SMITHA
Other - Middle Name:MARY
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1201 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1202172085B0100X, 2085N0904X, 2085R0202X
FLME1171572085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0073362Medicaid
OH204881619259OtherCARESOURCE
OH35.120217OtherLICENSE
OH710865OtherWELLCARE
OHH160480Medicare PIN