Provider Demographics
NPI:1144292202
Name:SMITHWICK, WALTER IV (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:SMITHWICK
Suffix:IV
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 1:2535 RIVERSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4710
Mailing Address - Country:US
Mailing Address - Phone:904-388-6548
Mailing Address - Fax:904-389-8157
Practice Address - Street 1:2535 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4710
Practice Address - Country:US
Practice Address - Phone:904-388-6548
Practice Address - Fax:904-389-8157
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75330207W00000X
FLME75330207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895199BMedicaid
FL2547864-00Medicaid
FL42856Medicare PIN
FL42856YMedicare PIN
GA000895199BMedicaid
FLP00388029Medicare PIN