Provider Demographics
NPI:1215991377
Name:SMITH, GERRY NIEMAN (MD)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:NIEMAN
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 1:548 ALLENS MILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2240
Mailing Address - Country:US
Mailing Address - Phone:757-496-2325
Mailing Address - Fax:
Practice Address - Street 1:1120 FIRST COLONIAL RD STE 206
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-496-2325
Practice Address - Fax:757-496-1942
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049815208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA400020904OtherIRS
VA1215991377Medicaid
VA250009135OtherRAILROAD
VA015476R53Medicare PIN