Provider Demographics
NPI:1780721860
Name:SMITH, MARK ANTHONY (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 FIVE OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8158
Mailing Address - Country:US
Mailing Address - Phone:770-724-0838
Mailing Address - Fax:
Practice Address - Street 1:285 BOULEVARD NE
Practice Address - Street 2:SUITE 610
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4205
Practice Address - Country:US
Practice Address - Phone:404-222-9914
Practice Address - Fax:404-524-5902
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007862111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor