Provider Demographics
NPI:1811080153
Name:SMITH, MARK A (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32008 ANCHORAGE LN
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:MD
Mailing Address - Zip Code:21635-1821
Mailing Address - Country:US
Mailing Address - Phone:410-441-9714
Mailing Address - Fax:
Practice Address - Street 1:1025 S YACHTSMAN DR
Practice Address - Street 2:
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-5012
Practice Address - Country:US
Practice Address - Phone:410-441-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-00070862084P0800X
FLME1578262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE100040241Medicaid
DE100040241Medicaid
DE492108Medicare ID - Type Unspecified