Provider Demographics
NPI:1104097963
Name:RENALDAS ALGIRDAS SMIDTAS
Entity type:Organization
Organization Name:RENALDAS ALGIRDAS SMIDTAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RENALDAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMIDTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-792-0753
Mailing Address - Street 1:413 NW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052
Mailing Address - Country:US
Mailing Address - Phone:386-792-0753
Mailing Address - Fax:
Practice Address - Street 1:413 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-7800
Practice Address - Country:US
Practice Address - Phone:386-792-0753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103986OtherAVMED
110117134OtherRAILROAD MEDICARE
FL27984OtherBCBS
FL378783400Medicaid
FL378783400Medicaid