Healthcare Provider Details

I. General information

NPI: 1841419058
Provider Name (Legal Business Name): CHARLES LEE SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 RED RD STE 501
MIRAMAR FL
33025
US

IV. Provider business mailing address

3600 RED RD STE 501
MIRAMAR FL
33025-6015
US

V. Phone/Fax

Practice location:
  • Phone: 954-947-3290
  • Fax: 866-572-2146
Mailing address:
  • Phone: 954-947-3290
  • Fax: 866-572-2146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberOS15367
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number832
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: