Provider Demographics
NPI:1194737122
Name:SMITH, LARRY C II (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:SMITH
Suffix:II
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 1:4058 SANDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-2222
Mailing Address - Country:US
Mailing Address - Phone:800-809-1265
Mailing Address - Fax:803-771-7782
Practice Address - Street 1:172 MCSWAIN DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:800-809-1265
Practice Address - Fax:803-771-7782
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT27824Medicaid
SC10147Medicare UPIN
SCD90884Medicare ID - Type Unspecified