Provider Demographics
NPI:1568579779
Name:SMITH, MELANIE A (DO)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-514-3700
Mailing Address - Fax:262-514-3867
Practice Address - Street 1:818 FOREST LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4585
Practice Address - Country:US
Practice Address - Phone:262-514-3700
Practice Address - Fax:262-514-3867
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30087300Medicaid
BS5574721OtherDEA NUMBER
G44143Medicare UPIN