Provider Demographics
NPI:1780901900
Name:SMITH, NELSON
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1210
Mailing Address - Country:US
Mailing Address - Phone:304-388-5590
Mailing Address - Fax:304-388-8238
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1210
Practice Address - Country:US
Practice Address - Phone:304-388-5590
Practice Address - Fax:304-388-8238
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2564208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine