Healthcare Provider Details

I. General information

NPI: 1245233840
Provider Name (Legal Business Name): JOAN SMITH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31664 OLD OCEAN CITY RD
SALISBURY MD
21804-1800
US

IV. Provider business mailing address

31664 OLD OCEAN CITY RD
SALISBURY MD
21804-1800
US

V. Phone/Fax

Practice location:
  • Phone: 410-334-3805
  • Fax: 410-860-5191
Mailing address:
  • Phone: 410-334-3805
  • Fax: 410-860-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH0048286
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: