Provider Demographics
NPI:1457568685
Name:SMILEY, JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SMILEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 CASSINE WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-0457
Mailing Address - Country:US
Mailing Address - Phone:850-231-1919
Mailing Address - Fax:850-231-1918
Practice Address - Street 1:43 CASSINE WAY STE 102
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-0457
Practice Address - Country:US
Practice Address - Phone:850-231-1919
Practice Address - Fax:850-231-1918
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44001207Q00000X
FLOS12346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010391100Medicaid
NENA1456014Medicare PIN
COCOA105247Medicare PIN
COCOA105246Medicare PIN