Healthcare Provider Details

I. General information

NPI: 1811080153
Provider Name (Legal Business Name): MARK A SMITH M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S YACHTSMAN DR
SANIBEL FL
33957-5012
US

IV. Provider business mailing address

32008 ANCHORAGE LN
GALENA MD
21635-1821
US

V. Phone/Fax

Practice location:
  • Phone: 410-441-9714
  • Fax:
Mailing address:
  • Phone: 410-441-9714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC1-0007086
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME157826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: