Provider Demographics
NPI:1912058579
Name:SMITH, VINCENT D (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:D
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:P.O. BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 WALNUT GROVE RD
Practice Address - Street 2:SUITE 627
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-763-1695
Practice Address - Fax:901-682-3150
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I110127Medicare PIN