Provider Demographics
NPI:1366853715
Name:SMITH, ABIGAIL (DPM)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 E PLAZA ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2044
Mailing Address - Country:US
Mailing Address - Phone:507-373-6133
Mailing Address - Fax:507-373-0261
Practice Address - Street 1:904 E PLAZA ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2044
Practice Address - Country:US
Practice Address - Phone:507-373-6133
Practice Address - Fax:507-373-0261
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDT.0000538213ES0103X
MN1082213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO13663853715Medicaid