Provider Demographics
NPI:1750426920
Name:SMITH, GEORGE LEON III (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:LEON
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1557
Mailing Address - Country:US
Mailing Address - Phone:770-786-0643
Mailing Address - Fax:770-787-0248
Practice Address - Street 1:4166 A NEWTON DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-786-0643
Practice Address - Fax:770-787-0248
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00247706BMedicaid
GA00247706BMedicaid