Provider Demographics
NPI:1194777953
Name:SMITH, NICHOLAS BRETT (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRETT
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 1:4600 FORT HENRY DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663
Mailing Address - Country:US
Mailing Address - Phone:423-224-3950
Mailing Address - Fax:423-224-3959
Practice Address - Street 1:1502 OXFORD DR STE 100
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8096
Practice Address - Country:US
Practice Address - Phone:502-570-3785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45319207Q00000X
VA0101253346207Q00000X
KY40228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01758949OtherRAILROAD MEDICARE
VA1194777953Medicaid
TN1515572Medicaid
TN3709285Medicare UPIN
TN103I083353Medicare PIN
TN1515572Medicaid
TNP01758949OtherRAILROAD MEDICARE