Provider Demographics
NPI:1720320864
Name:SMITH, DINOS JUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:DINOS
Middle Name:JUSTIN
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 1:293 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9445
Mailing Address - Country:US
Mailing Address - Phone:304-923-5904
Mailing Address - Fax:
Practice Address - Street 1:300 S PARK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8593
Practice Address - Country:US
Practice Address - Phone:800-815-8377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH34.013724207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty