Provider Demographics
NPI:1770677577
Name:SMITH, J DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:DOUGLAS
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4685 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:317-802-3140
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-802-3140
Practice Address - Fax:317-870-0499
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036090207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E05603Medicare UPIN
IN037870YMedicare ID - Type UnspecifiedMCARE #