Provider Demographics
NPI:1083699193
Name:SMITH, C RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:C
Middle Name:RICHARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2150 GETTLER ST STE 400
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2385
Practice Address - Country:US
Practice Address - Phone:219-865-0893
Practice Address - Fax:219-865-3599
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055627207RI0011X
IN02000747A207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055627Medicaid
IN100338620AMedicaid
IL572910Medicare PIN
IN406310FMedicare PIN
IN406090EMedicare PIN
IL036055627Medicaid