Provider Demographics
NPI:1255369732
Name:SMITH, STEPHANIE J (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3865
Practice Address - Country:US
Practice Address - Phone:770-297-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039472207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00824271AMedicaid
GA000824271BMedicaid
GA00824271AMedicaid
GA05BDGRRMedicare ID - Type Unspecified
GA2021726923Medicare PIN