Provider Demographics
NPI:1700862489
Name:SMITH, DAVID FERGUSON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:FERGUSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 SYLVANIA AVE
Mailing Address - Street 2:D1
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9729
Mailing Address - Country:US
Mailing Address - Phone:419-841-4099
Mailing Address - Fax:419-841-8025
Practice Address - Street 1:7640 SYLVANIA AVE
Practice Address - Street 2:D1
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9729
Practice Address - Country:US
Practice Address - Phone:419-841-4099
Practice Address - Fax:419-841-8125
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000051574OtherANTHEM
OHP00403185OtherRRMED
OH2757977Medicaid
00000051574OtherANTHEM
F59402Medicare UPIN