Healthcare Provider Details

I. General information

NPI: 1689820961
Provider Name (Legal Business Name): JIMSON OKON SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 NEW NORTHSIDE DR NW SUITE 320
ATLANTA GA
30328-5831
US

IV. Provider business mailing address

2106 MARSHALLS LN SE
ATLANTA GA
30316-2825
US

V. Phone/Fax

Practice location:
  • Phone: 770-874-5400
  • Fax:
Mailing address:
  • Phone: 404-243-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125049825
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number062289
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: