Healthcare Provider Details

I. General information

NPI: 1700034345
Provider Name (Legal Business Name): LARRY NELSON SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10925 SW 27TH AVE
GAINESVILLE FL
32608-8937
US

IV. Provider business mailing address

10925 SW 27TH AVE
GAINESVILLE FL
32608-8937
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-5626
  • Fax: 352-332-5759
Mailing address:
  • Phone: 352-332-5626
  • Fax: 352-332-5759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME 49162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: