Provider Demographics
NPI:1629399373
Name:SMITH, JOLENE M (DO)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ABIGAIL LN
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8746
Mailing Address - Country:US
Mailing Address - Phone:612-239-8673
Mailing Address - Fax:
Practice Address - Street 1:12499 UNIVERSITY AVE STE 280
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8288
Practice Address - Country:US
Practice Address - Phone:515-245-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54268207L00000X, 207LP2900X
IADO-04738207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA041880028Medicare PIN
MN050002559Medicare PIN