Provider Demographics
NPI:1811960412
Name:SMITH, STEPHEN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRL STE 505
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7521
Mailing Address - Country:US
Mailing Address - Phone:919-784-2300
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL STE 505
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7521
Practice Address - Country:US
Practice Address - Phone:919-784-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18719207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8978134Medicaid
NC8978134Medicaid
NC210544EMedicare PIN
NC8978134Medicaid
NC210544EMedicare PIN