Provider Demographics
NPI:1093885378
Name:SMITH, MARK ALAN (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 W WILLOW KNOLLS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-5800
Mailing Address - Fax:309-691-1336
Practice Address - Street 1:3322 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-5800
Practice Address - Fax:309-691-1336
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004790213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004790Medicaid
IL0007215174OtherBLUE CROSS BLUE SHIELD
IL928270OtherMEDICARE PROVIDER
IL480022534OtherRAILROAD MEDICARE
ILL55392Medicare PIN
IL0007215174OtherBLUE CROSS BLUE SHIELD
IL928270OtherMEDICARE PROVIDER