Healthcare Provider Details

I. General information

NPI: 1003017468
Provider Name (Legal Business Name): RYAN THOMAS SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 INTERSTATE PKWY
AUGUSTA GA
30909-5625
US

IV. Provider business mailing address

1330 INTERSTATE PKWY
AUGUSTA GA
30909-5625
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-2020
  • Fax: 706-855-6674
Mailing address:
  • Phone: 706-651-2020
  • Fax: 706-855-6674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number57009416
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number66645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: