Provider Demographics
NPI:1457463663
Name:SMITH, DAMANEON (DPM)
Entity Type:Individual
Prefix:
First Name:DAMANEON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 LEE HWY STE 303
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-1619
Mailing Address - Country:US
Mailing Address - Phone:703-538-5111
Mailing Address - Fax:703-538-4193
Practice Address - Street 1:5275 LEE HWY STE 303
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-1619
Practice Address - Country:US
Practice Address - Phone:703-538-5111
Practice Address - Fax:703-538-4193
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300902213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010031982Medicaid
VA6289370001OtherDME
VAP00831471OtherMCR-RR
VA491270Medicare ID - Type Unspecified
VA009152M58Medicare PIN
VAP00831471OtherMCR-RR