Healthcare Provider Details

I. General information

NPI: 1376517789
Provider Name (Legal Business Name): JAMES PHILLIP SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CHILD ST
JACKSONVILLE FL
32214-2538
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7419
  • Fax:
Mailing address:
  • Phone: 904-542-7419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01053765A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number65312
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME128170
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: