Provider Demographics
NPI:1780608984
Name:SMITH, PHILIP (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:SMITH
Suffix:
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 1:8221 WILLOW OAKS CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4512
Mailing Address - Country:US
Mailing Address - Phone:703-207-7818
Mailing Address - Fax:703-653-6692
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-207-7818
Practice Address - Fax:703-653-6692
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0344772084P0800X
VA01010581922084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101058192OtherMEDICAL LICENSE
DCMD034477OtherMEDICAL LICENSE
DCMD034477OtherMEDICAL LICENSE
MDD0057442OtherMEDICAL LICENSE
MDD0057442OtherMEDICAL LICENSE