Healthcare Provider Details

I. General information

NPI: 1013015080
Provider Name (Legal Business Name): THEDIA J SMITH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 VOLVO PKWY SUITE 200
CHESAPEAKE VA
23320-1609
US

IV. Provider business mailing address

733 VOLVO PKWY SUITE 200
CHESAPEAKE VA
23320-1609
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-5851
  • Fax: 888-371-4920
Mailing address:
  • Phone: 757-547-5851
  • Fax: 888-371-4920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101046052
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: