Healthcare Provider Details

I. General information

NPI: 1457041469
Provider Name (Legal Business Name): COLIN LUCAS SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SANDA AVE
WILLIAMSBURG VA
23185-5830
US

IV. Provider business mailing address

113 SANDA AVE
WILLIAMSBURG VA
23185-5830
US

V. Phone/Fax

Practice location:
  • Phone: 757-887-7639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102210239
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS21342
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: