Healthcare Provider Details

I. General information

NPI: 1922047562
Provider Name (Legal Business Name): THOMAS G SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33398 WALKER RD SUITE C
AVON LAKE OH
44012-1496
US

IV. Provider business mailing address

33398 WALKER RD SUITE C
AVON LAKE OH
44012-1496
US

V. Phone/Fax

Practice location:
  • Phone: 440-930-8630
  • Fax: 440-930-8676
Mailing address:
  • Phone: 440-930-8630
  • Fax: 440-930-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35036379
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35036379
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: