Provider Demographics
NPI:1558628396
Name:SMITH, DIONNE VANESSA (MD)
Entity Type:Individual
Prefix:MRS
First Name:DIONNE
Middle Name:VANESSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 G H BAKER DR
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1160
Mailing Address - Country:US
Mailing Address - Phone:217-326-6202
Mailing Address - Fax:
Practice Address - Street 1:1701 W. CURTIS RD.
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9678
Practice Address - Country:US
Practice Address - Phone:217-365-6202
Practice Address - Fax:217-326-0188
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138395208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program