Provider Demographics
NPI:1225488620
Name:SMITH, GWENDOLYN ROSE (DO)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:807 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1551
Practice Address - Country:US
Practice Address - Phone:864-455-9790
Practice Address - Fax:864-455-9795
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018950207Q00000X
NC2021-02165207Q00000X
SC91090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine