Provider Demographics
NPI:1790762870
Name:SMITH, THOMAS D III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:SMITH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1331 MINNICH RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2051
Practice Address - Country:US
Practice Address - Phone:260-373-9600
Practice Address - Fax:260-373-9602
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01027868A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053750Medicaid
00001291560 01OtherUNITED HEALTHCARE
IN080130028OtherRAILROAD MEDICARE
4047064OtherAETNA
IN000000111933OtherANTHEM
IN1867OtherPHYSICIANS HEALTH PLAN
4047064OtherAETNA
IN100053750Medicaid
IN070910CMedicare PIN
IN080130028OtherRAILROAD MEDICARE