Provider Demographics
NPI:1881796068
Name:SMITH, JUSTIN J (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19895 DETROIT RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1815
Mailing Address - Country:US
Mailing Address - Phone:440-356-5500
Mailing Address - Fax:440-356-0660
Practice Address - Street 1:19895 DETROIT RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-1815
Practice Address - Country:US
Practice Address - Phone:440-356-5500
Practice Address - Fax:440-356-0660
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197073Medicaid
OH000000141846OtherANTHEM
OH000000141846OtherANTHEM
OH2197073Medicaid