Provider Demographics
NPI:1558456574
Name:SMOLLER, MARTIN B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:B
Last Name:SMOLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:300 1ST CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2844
Mailing Address - Country:US
Mailing Address - Phone:636-949-7033
Mailing Address - Fax:636-949-7255
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:636-949-7255
Practice Address - Fax:636-949-7273
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR2329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12860Medicare UPIN