Provider Demographics
NPI:1538183371
Name:SMITH, ANGELA DEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:DEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 SHALLOWFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-870-9988
Mailing Address - Fax:423-870-9955
Practice Address - Street 1:6401 SHALLOWFORD ROAD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-870-9988
Practice Address - Fax:423-870-9955
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001001213E00000X
TNDPM585213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA596271187AMedicaid
TN3723317Medicaid
TN3353983Medicare ID - Type UnspecifiedPERFORMING PROVIDER
GA48SCCNQMedicare ID - Type UnspecifiedPERFORMING PROVIDER