Provider Demographics
NPI:1174541577
Name:SMITH, JOHN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-3321
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:834 W MEETING ST BLDG 4
Practice Address - Street 2:SUITE E
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6251
Practice Address - Country:US
Practice Address - Phone:803-285-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92941207V00000X
MN47458207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN420093400Medicaid
MN420093400Medicaid
I28447Medicare UPIN