Provider Demographics
NPI:1669882122
Name:SMITH, JUSTIN R (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:SMITH
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:BG CRAWFORD F. SAMS HEALTH CLINIC
Mailing Address - Street 2:UNIT 45011 BOX BG
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96343-5011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIT 45011 BOX BG
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96343-5011
Practice Address - Country:US
Practice Address - Phone:046-407-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022052832084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry