Healthcare Provider Details

I. General information

NPI: 1710450408
Provider Name (Legal Business Name): MISS GIVONSHY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2019
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10478 CAMPUS WAY S # 185
UPPER MARLBORO MD
20774-1304
US

IV. Provider business mailing address

10478 CAMPUS WAY S STE 185
UPPER MARLBORO MD
20774-1304
US

V. Phone/Fax

Practice location:
  • Phone: 240-883-6080
  • Fax:
Mailing address:
  • Phone: 240-883-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number419974
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number419974
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: