Provider Demographics
NPI:1427219567
Name:SMITH, DUSTIN JARED (MD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JARED
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 1:3710 CLOUDLAND DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2910
Mailing Address - Country:US
Mailing Address - Phone:208-585-1384
Mailing Address - Fax:
Practice Address - Street 1:2292 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1147
Practice Address - Country:US
Practice Address - Phone:404-996-0120
Practice Address - Fax:404-351-6762
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD156439207Q00000X
IDMR-0995207Q00000X
GA101661207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808095300Medicaid
OR500640264Medicaid
ORP01027050OtherRR MEDICARE (PROVIDENCE)
ORR163064Medicare PIN
ORR162851Medicare PIN
OR500640264Medicaid
ORR162854Medicare PIN
ORR162850Medicare PIN
ORR162853Medicare PIN
ORR167201Medicare PIN
ORR162852Medicare PIN
ORP01027050OtherRR MEDICARE (PROVIDENCE)