Provider Demographics
NPI:1144310624
Name:SMITH, DAVID PERRY (MD, FAAFP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PERRY
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD, FAAFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2062
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-2062
Mailing Address - Country:US
Mailing Address - Phone:704-288-3961
Mailing Address - Fax:888-869-8634
Practice Address - Street 1:1640 CAMPUS PARK DR STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5284
Practice Address - Country:US
Practice Address - Phone:704-288-3961
Practice Address - Fax:978-620-2361
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-02766207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0113837Medicaid
MS080003227Medicare PIN
MS0113837Medicaid