Provider Demographics
NPI:1417945122
Name:SMITH, WALTER K (MED, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:K
Last Name:SMITH
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 E COX DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9517
Mailing Address - Country:US
Mailing Address - Phone:812-336-2661
Mailing Address - Fax:812-855-1810
Practice Address - Street 1:1001 E 17TH ST
Practice Address - Street 2:ASSEMBLY HALL
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1590
Practice Address - Country:US
Practice Address - Phone:812-855-3621
Practice Address - Fax:812-855-1810
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000057A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer