Provider Demographics
NPI:1649984535
Name:SMITH, JOHN WALTON (PRSS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:SMITH
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3965
Mailing Address - Country:US
Mailing Address - Phone:304-792-8689
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON AVE STE 3
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3965
Practice Address - Country:US
Practice Address - Phone:304-792-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22-9138175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist