Provider Demographics
NPI:1316975618
Name:SMITH, JOHN HORATIO II (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HORATIO
Last Name:SMITH
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:HORATIO
Other - Last Name:SMITH
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:315 BOULEVARD NE STE 555
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1266
Mailing Address - Country:US
Mailing Address - Phone:404-223-1349
Mailing Address - Fax:404-223-3640
Practice Address - Street 1:315 BOULEVARD NE STE 555
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1266
Practice Address - Country:US
Practice Address - Phone:404-223-1349
Practice Address - Fax:404-223-3640
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000875223IMedicaid
GAH43120Medicare UPIN
GA000875223IMedicaid