Provider Demographics
NPI:1649210857
Name:SMITH, CAMILLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 DUPONT COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2393
Mailing Address - Country:US
Mailing Address - Phone:260-490-7337
Mailing Address - Fax:260-489-8937
Practice Address - Street 1:2810 DUPONT COMMERCE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2393
Practice Address - Country:US
Practice Address - Phone:260-490-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060084A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200518300Medicaid
IN290975OtherHARMONY