Provider Demographics
NPI:1174884662
Name:SMITH, NATHAN (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
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 1:750 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5010
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:
Practice Address - Street 1:1500 OLGETHORPE AVE BLDG 500
Practice Address - Street 2:STE A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:678-971-4167
Practice Address - Fax:833-989-2501
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29319207L00000X
GA77552208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003214027KMedicaid