Provider Demographics
NPI:1649485160
Name:SMITH, JOSHUA POPPELL
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:POPPELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
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 750
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31515-0750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0244
Practice Address - Country:US
Practice Address - Phone:912-293-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0679972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology