Provider Demographics
NPI:1811930266
Name:SMITH, GARY (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-7619
Mailing Address - Fax:850-416-7753
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:SHMG HOSPITALIST
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7619
Practice Address - Fax:850-416-7753
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD01697207R00000X
FLOS13799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010167337Medicaid
FL0167370-00Medicaid
TN103I117656Medicare PIN
H89954Medicare UPIN
VA010167337Medicaid