Provider Demographics
NPI:1316660632
Name:SMITH, JOHN THOMAS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2307
Mailing Address - Country:US
Mailing Address - Phone:681-372-6922
Mailing Address - Fax:
Practice Address - Street 1:1057 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2307
Practice Address - Country:US
Practice Address - Phone:681-372-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist