Provider Demographics
NPI:1154671394
Name:SMITH, JUSTIN DARREN (CSFA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DARREN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11854 214TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:WI
Mailing Address - Zip Code:53104
Mailing Address - Country:US
Mailing Address - Phone:847-561-7460
Mailing Address - Fax:
Practice Address - Street 1:2520 ELISHA AVENUE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099
Practice Address - Country:US
Practice Address - Phone:847-561-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000298171W00000X
246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No171W00000XOther Service ProvidersContractor