Provider Demographics
NPI:1841633757
Name:SMITH, BRENTLEY (MD)
Entity type:Individual
Prefix:DR
First Name:BRENTLEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRENT
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:699 CHURCH ST NE STE 235
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1132
Mailing Address - Country:US
Mailing Address - Phone:770-792-6262
Mailing Address - Fax:
Practice Address - Street 1:699 CHURCH ST NE STE 235
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1132
Practice Address - Country:US
Practice Address - Phone:770-792-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA86188207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program