Provider Demographics
NPI:1609063155
Name:CARLOS F SMITH DPM PC
Entity Type:Organization
Organization Name:CARLOS F SMITH DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-642-3440
Mailing Address - Street 1:711 W NORTH AVE
Mailing Address - Street 2:STE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1042
Mailing Address - Country:US
Mailing Address - Phone:312-642-3440
Mailing Address - Fax:312-642-4319
Practice Address - Street 1:711 W NORTH AVE
Practice Address - Street 2:STE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1042
Practice Address - Country:US
Practice Address - Phone:312-642-3440
Practice Address - Fax:312-642-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004833213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480035349OtherPALMETTO GBA
IL016004833Medicaid
IL480035349OtherPALMETTO GBA
IL1326100001Medicare NSC