Provider Demographics
NPI:1215110192
Name:RENALDAS ALGIRDAS SMIDTAS
Entity type:Organization
Organization Name:RENALDAS ALGIRDAS SMIDTAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENALDAS
Authorized Official - Middle Name:ALGIRDAS
Authorized Official - Last Name:SMIDTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-362-5840
Mailing Address - Street 1:1437 N OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4817
Mailing Address - Country:US
Mailing Address - Phone:386-362-5840
Mailing Address - Fax:
Practice Address - Street 1:1437 N OHIO AVE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4817
Practice Address - Country:US
Practice Address - Phone:386-362-5840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENALDAS SMIDTAS MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069486207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110212209OtherRAILROAD MEDICARE GA
FL27984AOtherBCBS
FL103986OtherAVMED
FL378783401Medicaid
FL378783401Medicaid