Provider Demographics
NPI:1508861436
Name:SMITH, VANCE HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:HOWARD
Last Name:SMITH
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 1:296 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3733
Mailing Address - Country:US
Mailing Address - Phone:231-737-8814
Mailing Address - Fax:231-733-2217
Practice Address - Street 1:296 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3733
Practice Address - Country:US
Practice Address - Phone:231-737-8814
Practice Address - Fax:231-733-2217
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8152086S0129X
MI27122208D00000X
INICAVL 6/922085R0204X
MIRENAL PTA'S1744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No1744R1102XOther Service ProvidersSpecialistResearch Study
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3089083Medicaid
MI4619658Medicaid
MI0616238Medicare ID - Type Unspecified
MI4619658Medicaid