Provider Demographics
NPI:1104259522
Name:SMITH, ANTOINE LAMONT SR (HS)
Entity type:Individual
Prefix:
First Name:ANTOINE
Middle Name:LAMONT
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 SHOTGUN RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-4512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1260 SHOTGUN RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-4512
Practice Address - Country:US
Practice Address - Phone:757-421-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians