Provider Demographics
NPI:1730234477
Name:SMITH, BRYAN D
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:
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 1630
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28370-1630
Mailing Address - Country:US
Mailing Address - Phone:910-295-6007
Mailing Address - Fax:910-215-0179
Practice Address - Street 1:4102 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2140
Practice Address - Country:US
Practice Address - Phone:919-972-7700
Practice Address - Fax:910-216-0179
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002015312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891376RMedicaid
NC1376ROtherBLUE CROSS BLUE SHIELD
NC2012230Medicare PIN
NC1376ROtherBLUE CROSS BLUE SHIELD