Healthcare Provider Details

I. General information

NPI: 1093079204
Provider Name (Legal Business Name): CAROLYN RUTH SMALLWOOD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 WHITE CIR SUITE 105
MARIETTA GA
30066-5835
US

IV. Provider business mailing address

1810 WHITE CIR SUITE 105
MARIETTA GA
30066-5835
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-6820
  • Fax: 770-424-8787
Mailing address:
  • Phone: 678-797-6820
  • Fax: 770-424-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL4519
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74101
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: