Provider Demographics
NPI:1992807242
Name:SMITH, GREGORY SCOTT (MEDICAL DOCTOR)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 JEFFERSON PL STE 1
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1761
Mailing Address - Country:US
Mailing Address - Phone:706-548-0058
Mailing Address - Fax:706-548-0555
Practice Address - Street 1:21 JEFFERSON PL
Practice Address - Street 2:SUITE 1
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1761
Practice Address - Country:US
Practice Address - Phone:706-548-0058
Practice Address - Fax:706-548-0555
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047532207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA047532OtherSTATE LICENSE NUMBER
GA000817099CMedicaid
GA047532OtherSTATE LICENSE NUMBER
GA10BBCLVMedicare ID - Type Unspecified