Healthcare Provider Details

I. General information

NPI: 1265528558
Provider Name (Legal Business Name): SALLY SOCKWELL SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-6691
  • Fax: 910-615-5398
Mailing address:
  • Phone: 910-615-6691
  • Fax: 910-615-5398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number34221
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: