Provider Demographics
NPI:1548462393
Name:SMITH, TERRI LYNETTE (DO)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4003 HARBOR VIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-1997
Mailing Address - Country:US
Mailing Address - Phone:904-764-7109
Mailing Address - Fax:
Practice Address - Street 1:2804 W MARC KNIGHTON CT
Practice Address - Street 2:SUITE A
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6300
Practice Address - Country:US
Practice Address - Phone:352-749-8000
Practice Address - Fax:352-749-8003
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDO1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG59977Medicare UPIN