Healthcare Provider Details

I. General information

NPI: 1598767857
Provider Name (Legal Business Name): CARYN J. MASTERMAN-SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 02/10/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CHURCH ST
VIDALIA GA
30474-4770
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-538-8484
  • Fax: 912-538-8665
Mailing address:
  • Phone: 912-537-4986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS8651
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63712
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: