Provider Demographics
NPI:1508594631
Name:SMITH, MARK DAVID
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 COUNTY ROAD 510
Mailing Address - Street 2:
Mailing Address - City:WAPPAPELLO
Mailing Address - State:MO
Mailing Address - Zip Code:63966-8267
Mailing Address - Country:US
Mailing Address - Phone:573-772-2115
Mailing Address - Fax:
Practice Address - Street 1:109 PLUM ST
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1277
Practice Address - Country:US
Practice Address - Phone:573-663-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019041549207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019041549OtherMEDICAL LICENSE NUMBER