Provider Demographics
NPI:1669618278
Name:SMITH, STEPHEN R (RD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 6TH ST S APT 2
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4405
Mailing Address - Country:US
Mailing Address - Phone:727-608-8107
Mailing Address - Fax:
Practice Address - Street 1:325 6TH ST S APT 2
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4405
Practice Address - Country:US
Practice Address - Phone:727-608-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5337133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered