Provider Demographics
NPI:1073501912
Name:SMACK, DAVID PHILLIPS (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PHILLIPS
Last Name:SMACK
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:PO BOX 2350
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-8945
Mailing Address - Country:US
Mailing Address - Phone:410-822-9890
Mailing Address - Fax:410-763-9536
Practice Address - Street 1:5 CAULK LANE
Practice Address - Street 2:SUITE 2, 2ND FLOOR
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4066
Practice Address - Country:US
Practice Address - Phone:410-822-9890
Practice Address - Fax:410-763-9536
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040409207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD070010482OtherMC RAILROAD
MD21D0931132OtherCLIA
MDKB59TAOtherBLUE SHIELD
MDW0170001OtherBLUE SHIELD
MD248038OtherMAMSI PLANS
MD248038OtherMAMSI PLANS
MD538M835FMedicare ID - Type Unspecified