Provider Demographics
NPI:1750484879
Name:SMITH, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14734 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1927
Mailing Address - Country:US
Mailing Address - Phone:231-547-6554
Mailing Address - Fax:231-547-1179
Practice Address - Street 1:14734 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1927
Practice Address - Country:US
Practice Address - Phone:231-547-6554
Practice Address - Fax:231-547-1179
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2014-07-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301076489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8002922550Medicaid
MI8002922550Medicaid
MIH76753Medicare UPIN