Provider Demographics
NPI:1528023884
Name:SMITH, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
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 1:507 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-2059
Mailing Address - Country:US
Mailing Address - Phone:608-637-2101
Mailing Address - Fax:
Practice Address - Street 1:507 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2059
Practice Address - Country:US
Practice Address - Phone:608-637-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32768-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31770300Medicaid
WI3741OtherDEAN HEALTH INSURANCE
WI1013472OtherPHYSICIANS PLUS
MN41A65SMOtherBLUE CROSS BLUE SHIELD
WI1013472OtherPHYSICIANS PLUS
WI080179014Medicare PIN
F17007Medicare UPIN