Provider Demographics
NPI:1518375682
Name:SMITH, DEREK (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 IROQUOIS CIR
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1248
Mailing Address - Country:US
Mailing Address - Phone:608-408-0065
Mailing Address - Fax:
Practice Address - Street 1:809 IROQUOIS CIR
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1248
Practice Address - Country:US
Practice Address - Phone:608-408-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4980111N00000X
TN2650111N00000X
MO2013007171111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor