Provider Demographics
NPI:1104817014
Name:SMITH, ETHEL L (MD)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2020 HONEY CREEK PKWY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013
Mailing Address - Country:US
Mailing Address - Phone:770-919-0813
Mailing Address - Fax:770-929-3868
Practice Address - Street 1:2020 HONEY CREEK PKWY SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013
Practice Address - Country:US
Practice Address - Phone:770-919-0813
Practice Address - Fax:770-929-3868
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E30562Medicare UPIN
GA08BBQWCMedicare ID - Type Unspecified