Healthcare Provider Details

I. General information

NPI: 1225127129
Provider Name (Legal Business Name): TAMARA SUSAN SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14535 JOHN MARSHALL HWY, SUITE 212
GAINESVILLE VA
20155-4025
US

IV. Provider business mailing address

224 D CORNWALL STREET NW STE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 571-248-0245
  • Fax: 571-248-0241
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101243112
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21653
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101243112
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: