Provider Demographics
NPI:1093918476
Name:SMUCKER, JON B (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:B
Last Name:SMUCKER
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 1:2310 CALIFORNIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-0791
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA RD STE A
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-0791
Practice Address - Fax:574-262-5183
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10167873A207X00000X
IN01067873A207XX0005X
FLME103931207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200981040Medicaid
INM400021476Medicare PIN