Provider Demographics
NPI:1760421408
Name:SMITH, ROBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1106
Mailing Address - Country:US
Mailing Address - Phone:937-208-7100
Mailing Address - Fax:937-208-7125
Practice Address - Street 1:360 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-1106
Practice Address - Country:US
Practice Address - Phone:937-208-7100
Practice Address - Fax:937-208-7125
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.003325208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0649098Medicaid
D89773Medicare UPIN
OH0649098Medicaid
OH0544146Medicare PIN