Basic Information
| Provider Information | |||||||||
| NPI: | 1487636379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DELIA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741087 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507698341 | ||||||||
| FaxNumber: | 8503255173 | ||||||||
| Practice Location | |||||||||
| Address1: | 449 W 23RD ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507698341 | ||||||||
| FaxNumber: | 8503255173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME147647 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 266173000 | 05 | FL | MEDICAID | 550033371 | 01 | RAILROAD MEDICARE | OTHER |