Healthcare Provider Details

I. General information

NPI: 1861858268
Provider Name (Legal Business Name): FITZROY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5728 CONSTANCE CT
VIRGINIA BEACH VA
23462-1063
US

IV. Provider business mailing address

5728 CONSTANCE CT
VIRGINIA BEACH VA
23462-1063
US

V. Phone/Fax

Practice location:
  • Phone: 757-292-0541
  • Fax:
Mailing address:
  • Phone: 757-292-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: