Provider Demographics
NPI:1154393841
Name:SMITH, GORDON V (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:V
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2055 NORMANDIE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-269-6337
Mailing Address - Fax:334-834-0657
Practice Address - Street 1:2055 NORMANDIE DR
Practice Address - Street 2:108
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2732
Practice Address - Country:US
Practice Address - Phone:334-288-4624
Practice Address - Fax:334-280-3628
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL000249742085R0202X
GA0448772085R0202X
FLME901992085R0202X
ALMD249742085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL106707Medicaid
AL108067Medicaid
AL107000Medicaid
AL108566Medicaid
AL009922425Medicaid
AL108067Medicaid
000058867Medicare PIN
000058866Medicare PIN
FL43119YMedicare PIN
051552874Medicare PIN
051552875Medicare PIN
G90322Medicare UPIN
AL107000Medicaid