Provider Demographics
NPI:1376536433
Name:SMITH, TIMOTHY W (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:W
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 1:289 A NORTHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3679
Mailing Address - Country:US
Mailing Address - Phone:513-742-1777
Mailing Address - Fax:513-742-2392
Practice Address - Street 1:289 A NORTHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3679
Practice Address - Country:US
Practice Address - Phone:513-742-1777
Practice Address - Fax:513-742-2392
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004608208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0713768Medicaid
OHSM0637965Medicare PIN