Provider Demographics
NPI:1841943644
Name:SMITH, ANTONIO LEE
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 LYNWOOD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5951
Mailing Address - Country:US
Mailing Address - Phone:304-206-1503
Mailing Address - Fax:
Practice Address - Street 1:54 LYNWOOD AVE APT 2
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5951
Practice Address - Country:US
Practice Address - Phone:304-206-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF508489172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty