Provider Demographics
NPI:1255330965
Name:SMITH, COLLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HEALTHY PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7067
Mailing Address - Country:US
Mailing Address - Phone:220-564-1900
Mailing Address - Fax:220-564-1901
Practice Address - Street 1:1 HEALTHY PL
Practice Address - Street 2:SUITE 101
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7067
Practice Address - Country:US
Practice Address - Phone:220-564-1900
Practice Address - Fax:220-564-1901
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079346207Q00000X
OH35-079346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2230722Medicaid
OHH276870Medicare PIN