Provider Demographics
NPI:1215035050
Name:SMITH, DONALD E (CRNA)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRYSTAL GATE LN
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1134
Mailing Address - Country:US
Mailing Address - Phone:618-288-9867
Mailing Address - Fax:
Practice Address - Street 1:1515 MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1656
Practice Address - Country:US
Practice Address - Phone:619-526-5329
Practice Address - Fax:618-526-2291
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041289062367500000X
IL209004059367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL558390Medicare ID - Type Unspecified