Provider Demographics
NPI:1639168156
Name:SMITH, STEPHEN LOWELL (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:LOWELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 LESSAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1025
Mailing Address - Country:US
Mailing Address - Phone:904-315-5505
Mailing Address - Fax:
Practice Address - Street 1:39 LESSAY
Practice Address - Street 2:
Practice Address - City:NEWPORT COAST
Practice Address - State:CA
Practice Address - Zip Code:92657-1025
Practice Address - Country:US
Practice Address - Phone:904-315-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61688208600000X
CAG52278208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266978OtherAVMED
GA823712756AMedicaid
FLP00676831OtherRAILROAD MEDICARE
3646090OtherCIGNA
FL4043095OtherAETNA
FL14611OtherBLUECROSS/BLUESHIELD
FLA52219Medicare UPIN
FL14611YMedicare PIN