Provider Demographics
NPI:1871889170
Name:SMITH, ELYSIA (DO)
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELYSIA
Other - Middle Name:
Other - Last Name:MALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1124 WAKEFIELD FARM RD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-7353
Mailing Address - Country:US
Mailing Address - Phone:972-768-0129
Mailing Address - Fax:
Practice Address - Street 1:3000 AERIAL CENTER PKWY STE 130
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-0077
Practice Address - Country:US
Practice Address - Phone:919-461-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01646207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine