Healthcare Provider Details

I. General information

NPI: 1790784361
Provider Name (Legal Business Name): KEVIN F SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 NELSON BROGDON BLVD SUITE D1
BUFORD GA
30518-3447
US

IV. Provider business mailing address

300 COLONIAL CENTER PKWY SUITE 100
ROSWELL GA
30076-4899
US

V. Phone/Fax

Practice location:
  • Phone: 770-932-9998
  • Fax: 770-457-3018
Mailing address:
  • Phone: 770-286-9149
  • Fax: 770-457-3018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number041961
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number041961
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: