Provider Demographics
NPI:1326134339
Name:SMITH, DONALD WILFRED (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WILFRED
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49920-1503
Mailing Address - Country:US
Mailing Address - Phone:906-875-6681
Mailing Address - Fax:906-875-3090
Practice Address - Street 1:211 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1503
Practice Address - Country:US
Practice Address - Phone:906-875-6681
Practice Address - Fax:906-875-3090
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI01536025605OtherBLUE CROSS BLUE SHIELD
MI5360256Medicare ID - Type Unspecified
MI01536025605OtherBLUE CROSS BLUE SHIELD