Provider Demographics
NPI:1194732719
Name:SMITH, MARTHA (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD STE A
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8852
Practice Address - Country:US
Practice Address - Phone:912-535-3500
Practice Address - Fax:912-535-4498
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38614207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607549NMedicaid
GA000607549NMedicaid
GAE42914Medicare UPIN