Healthcare Provider Details

I. General information

NPI: 1568571263
Provider Name (Legal Business Name): RENALDAS SMIDTAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 NW 5TH AVE
JASPER FL
32052
US

IV. Provider business mailing address

413 NW 5TH AVE
JASPER FL
32052
US

V. Phone/Fax

Practice location:
  • Phone: 386-792-0753
  • Fax: 386-792-2412
Mailing address:
  • Phone: 386-792-0753
  • Fax: 386-792-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0069486
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: