Provider Demographics
NPI:1750814869
Name:SMITH, ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
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 1:4201 SAINT ANTOINE ST # 2E
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST # 2E
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01084090207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine