Provider Demographics
NPI:1700871241
Name:SMITH, DOMINIQUE J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 HILLANDALE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3892
Mailing Address - Country:US
Mailing Address - Phone:678-418-6990
Mailing Address - Fax:678-418-6986
Practice Address - Street 1:5900 HILLANDALE DR STE 325
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3892
Practice Address - Country:US
Practice Address - Phone:678-418-6990
Practice Address - Fax:678-418-6986
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042439207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000740737IMedicaid
16BBCSXMedicare PIN
GAG46213Medicare UPIN