Provider Demographics
NPI:1932867157
Name:SMITH, MARY S (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10096 ANDEAN FOX DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-4153
Mailing Address - Country:US
Mailing Address - Phone:904-383-5916
Mailing Address - Fax:
Practice Address - Street 1:328 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5536
Practice Address - Country:US
Practice Address - Phone:904-383-5916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-05
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty