Healthcare Provider Details

I. General information

NPI: 1851655203
Provider Name (Legal Business Name): ANDREW JOSEPH SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2012
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N BONITA AVE
PANAMA CITY FL
32401
US

IV. Provider business mailing address

5301 S CONGRESS AVE
ATLANTIS FL
33462-1149
US

V. Phone/Fax

Practice location:
  • Phone: 850-747-2036
  • Fax: 850-769-7545
Mailing address:
  • Phone: 877-832-2652
  • Fax: 800-792-9021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2012021976
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN19206
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME133141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: