Provider Demographics
NPI:1477556918
Name:SMOTHERS, MICHAEL ELLSWORTH (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ELLSWORTH
Last Name:SMOTHERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 E LAKE DR S
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4327
Mailing Address - Country:US
Mailing Address - Phone:574-206-0465
Mailing Address - Fax:574-262-5217
Practice Address - Street 1:3003 E LAKE DR S
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4327
Practice Address - Country:US
Practice Address - Phone:574-206-0465
Practice Address - Fax:574-262-5217
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-28
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042198207Q00000X, 207QG0300X
MI4301042611207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N76240Medicare ID - Type Unspecified
INB46790Medicare UPIN
IN149240Medicare ID - Type Unspecified