Healthcare Provider Details

I. General information

NPI: 1932867157
Provider Name (Legal Business Name): MARY S SMITH SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 MILWAUKEE AVE
ORANGE PARK FL
32073-5536
US

IV. Provider business mailing address

10096 ANDEAN FOX DR
JACKSONVILLE FL
32222-4153
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-5916
  • Fax:
Mailing address:
  • Phone: 904-383-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: