Healthcare Provider Details

I. General information

NPI: 1437310422
Provider Name (Legal Business Name): DUSTIN K SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 1 MAYPORT AVENUE
MAYPORT FL
32228
US

IV. Provider business mailing address

MAYPORT AVENUE, BUILDING 1
MAYPORT FL
32228
US

V. Phone/Fax

Practice location:
  • Phone: 904-635-5165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003741A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: