Provider Demographics
NPI:1679520050
Name:SMITH, DAVID RUSSELL (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RUSSELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 ENDRICK CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-9564
Mailing Address - Country:US
Mailing Address - Phone:919-616-5704
Mailing Address - Fax:
Practice Address - Street 1:2509 RICHARDSON DR STE A
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5926
Practice Address - Country:US
Practice Address - Phone:336-347-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00863363AS0400X, 363A00000X
MO2006017175363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0600090OtherUNITED HEALTHCARE
MO209151OtherANTHEM BLUE CROSS/SHIELD
MO2561566OtherCOX HEALTH
MO502277007Medicaid
MO000097331Medicare ID - Type UnspecifiedMISSOURI MEDICARE
NC2770093Medicare PIN
MO0600090OtherUNITED HEALTHCARE