Healthcare Provider Details

I. General information

NPI: 1669882122
Provider Name (Legal Business Name): JUSTIN R SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 45011 BOX BG
APO AP
96343-5011
US

IV. Provider business mailing address

BG CRAWFORD F. SAMS HEALTH CLINIC UNIT 45011 BOX BG
APO AP
96343-5011
US

V. Phone/Fax

Practice location:
  • Phone: 46-407-4175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102205283
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: