Provider Demographics
NPI:1124175542
Name:SMITH, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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 1:4321 FAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-5723
Mailing Address - Country:US
Mailing Address - Phone:901-386-6399
Mailing Address - Fax:901-372-2135
Practice Address - Street 1:4321 FAYETTE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5723
Practice Address - Country:US
Practice Address - Phone:901-386-6399
Practice Address - Fax:901-372-2135
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14078170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3191844Medicare ID - Type Unspecified
TNB04490Medicare UPIN