Provider Demographics
NPI:1053395871
Name:SMITH, EDWARD NATHANIEL (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:NATHANIEL
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 1:7799 LEESBURG PIKE
Mailing Address - Street 2:SUITE 1000 N
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22043-2408
Mailing Address - Country:US
Mailing Address - Phone:703-667-8600
Mailing Address - Fax:
Practice Address - Street 1:3301 NEW MEXICO AVE NW
Practice Address - Street 2:SUITE 106
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-3622
Practice Address - Country:US
Practice Address - Phone:202-966-0606
Practice Address - Fax:202-244-6757
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD161702085R0202X
MDD00319862085R0202X
VAO1012253732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD855103100Medicaid
FMX003Medicare PIN
MD575P182HMedicare PIN
DC010992W30Medicare ID - Type Unspecified
MD784M363FMedicare PIN
300135373Medicare PIN
470001526Medicare PIN
DC00B419O31Medicare UPIN
MD855103100Medicaid
DC010992W30Medicare PIN