Provider Demographics
NPI:1023005436
Name:SMITH, WAYNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:A
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 1:5855 MONROE ST.
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2269
Mailing Address - Country:US
Mailing Address - Phone:419-824-7338
Mailing Address - Fax:419-824-7359
Practice Address - Street 1:781 LAKESHIRE TRAIL
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1561
Practice Address - Country:US
Practice Address - Phone:517-265-0600
Practice Address - Fax:517-263-0024
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072226207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3470600Medicaid
MI0M61230Medicare ID - Type Unspecified
MIM35150081Medicare PIN
MI3470600Medicaid