Provider Demographics
NPI:1104817410
Name:SMITH, SIDNEY P (MD)
Entity type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:P
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 1:900 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1780
Mailing Address - Country:US
Mailing Address - Phone:912-925-0067
Mailing Address - Fax:912-927-0267
Practice Address - Street 1:900 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1780
Practice Address - Country:US
Practice Address - Phone:912-925-0067
Practice Address - Fax:912-927-0267
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038615207NS0135X, 207N00000X, 207ND0900X, 207NP0225X, 207R00000X, 207ND0101X
GA38615207Q00000X
SC17623207N00000X, 207ND0900X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA722272524AMedicaid
SC176231Medicaid
GA722272524BMedicaid
GA000637909CMedicaid
GA722272524CMedicaid
GAE68293Medicare UPIN
SCE682938312Medicare ID - Type Unspecified
GA07BDCMCMedicare ID - Type Unspecified
GA722272524AMedicaid