Provider Demographics
NPI:1598534588
Name:SMITH, DOMINIQUE
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:
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 1:9511 PERRIN BEITEL RD APT 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-3538
Mailing Address - Country:US
Mailing Address - Phone:713-393-9739
Mailing Address - Fax:
Practice Address - Street 1:9511 PERRIN BEITEL RD APT 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-3538
Practice Address - Country:US
Practice Address - Phone:713-393-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNHA346213211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric