Provider Demographics
NPI:1568480879
Name:SMITH, WENDELL ROBERT
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2329
Mailing Address - Country:US
Mailing Address - Phone:218-749-7953
Mailing Address - Fax:218-749-7952
Practice Address - Street 1:1101 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2329
Practice Address - Country:US
Practice Address - Phone:218-749-7953
Practice Address - Fax:218-749-7952
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44610208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN321240800Medicaid
MN020002078Medicare PIN
H58716Medicare UPIN