Provider Demographics
NPI:1043311731
Name:SMITH, CYNTHIA (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 N ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9230
Mailing Address - Country:US
Mailing Address - Phone:231-935-0555
Mailing Address - Fax:231-935-0562
Practice Address - Street 1:5024 N ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-9230
Practice Address - Country:US
Practice Address - Phone:231-935-0555
Practice Address - Fax:231-935-0562
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICS045398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2858335Medicaid
MI2858335Medicaid
MION59340Medicare ID - Type Unspecified