Provider Demographics
NPI:1265528558
Name:SMITH, SALLY SOCKWELL (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:SOCKWELL
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1638 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-6691
Mailing Address - Fax:910-615-5398
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-615-6691
Practice Address - Fax:910-615-5398
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC342212085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8945338Medicaid
NC8945338Medicaid
F65094Medicare UPIN