Healthcare Provider Details

I. General information

NPI: 1194737122
Provider Name (Legal Business Name): LARRY C SMITH II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 MCSWAIN DRIVE SUITE A
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

4058 SANDWOOD DR
COLUMBIA SC
29206-2222
US

V. Phone/Fax

Practice location:
  • Phone: 800-809-1265
  • Fax: 803-771-7782
Mailing address:
  • Phone: 800-809-1265
  • Fax: 803-771-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18842
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: