Healthcare Provider Details

I. General information

NPI: 1609067750
Provider Name (Legal Business Name): TALETHA BRENTS SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

5605 GLENRIDGE DR STE 325
ATLANTA GA
30342-1365
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6323
  • Fax: 404-303-3747
Mailing address:
  • Phone: 678-553-7783
  • Fax: 678-553-7793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD.200356
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number21442
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number200356
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number077667
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: