Healthcare Provider Details

I. General information

NPI: 1871558114
Provider Name (Legal Business Name): MARK ANTHONY SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13460 BEACH BLVD STE 1
JACKSONVILLE FL
32224-0301
US

IV. Provider business mailing address

2925 LEON RD
JACKSONVILLE FL
32246-3664
US

V. Phone/Fax

Practice location:
  • Phone: 904-854-1700
  • Fax:
Mailing address:
  • Phone: 904-536-6755
  • Fax: 904-646-0278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME77870
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME77870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: