Healthcare Provider Details

I. General information

NPI: 1851778542
Provider Name (Legal Business Name): PAUL SMITH D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE
ATLANTA GA
30322-1010
US

IV. Provider business mailing address

195 13TH ST NE UNIT 1504
ATLANTA GA
30309-4817
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-0480
  • Fax:
Mailing address:
  • Phone: 313-622-4931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number85123
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number85123
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: