Provider Demographics
NPI:1780862763
Name:SMITH, JOHN RANDOLPH (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDOLPH
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:301 S ELM ST
Mailing Address - Street 2:SUITE 305-6
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2696
Mailing Address - Country:US
Mailing Address - Phone:336-674-8741
Mailing Address - Fax:336-674-8877
Practice Address - Street 1:301 S ELM ST
Practice Address - Street 2:SUITE 305-6
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2696
Practice Address - Country:US
Practice Address - Phone:336-674-8741
Practice Address - Fax:336-674-8877
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC98-015022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
72586EMedicare UPIN