MEDICARE: DR. DIANE K SMITH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	023111	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376541292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE K SMITH M.D.

Provider Business Mailing Address
First Line	:	1220 AUGUSTA WEST PKWY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-1808
Country	:	US
Telephone Number	:	706-860-3001
Fax Number	:	706-860-0305

Provider Business Practice Location Address
First Line	:	1220 AUGUSTA WEST PKWY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-1808
Country	:	US
Telephone Number	:	706-860-3001
Fax Number	:	706-860-0305

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/08/2007

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