Provider Demographics
NPI:1538103403
Name:SMITH, JONATHAN MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S 2ND ST
Mailing Address - Street 2:PO BOX 575
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-1664
Mailing Address - Country:US
Mailing Address - Phone:260-724-7179
Mailing Address - Fax:260-724-8532
Practice Address - Street 1:145 S 2ND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1664
Practice Address - Country:US
Practice Address - Phone:260-724-7179
Practice Address - Fax:260-724-8532
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000685213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100359030Medicaid
IN480024190OtherRAIL ROAD
IN100359030Medicaid
IN256540Medicare PIN