Provider Demographics
NPI:1801991773
Name:SMITH, IVY YVONNE (MD)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:YVONNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HANDLEY RD
Mailing Address - Street 2:STE 410
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1625
Mailing Address - Country:US
Mailing Address - Phone:770-964-5810
Mailing Address - Fax:678-364-1216
Practice Address - Street 1:120 HANDLEY RD
Practice Address - Street 2:STE 410
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1625
Practice Address - Country:US
Practice Address - Phone:770-964-5810
Practice Address - Fax:678-364-1216
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA407530212BMedicaid
H83194Medicare UPIN
GA407530212BMedicaid