Healthcare Provider Details

I. General information

NPI: 1871546515
Provider Name (Legal Business Name): CLEATIOUS DAVID SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14088 ALABAMA ST
JAY FL
32565
US

IV. Provider business mailing address

PO BOX 10 14088 ALABAMA ST
JAY FL
32565
US

V. Phone/Fax

Practice location:
  • Phone: 850-675-4546
  • Fax: 850-675-4548
Mailing address:
  • Phone: 850-675-4546
  • Fax: 850-675-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME36891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: