Provider Demographics
NPI:1821080409
Name:SMITH, PETER C (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GRANITE RUN DRIVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-6809
Mailing Address - Country:US
Mailing Address - Phone:717-560-4310
Mailing Address - Fax:717-560-3452
Practice Address - Street 1:300 GRANITE RUN DRIVE
Practice Address - Street 2:SUITE 160
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6809
Practice Address - Country:US
Practice Address - Phone:717-560-4310
Practice Address - Fax:717-560-3452
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003298L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014543670004Medicaid
PA480019276OtherRAIL ROAD MEDICARE
PA480019276OtherRAIL ROAD MEDICARE
PA0014543670004Medicaid
PA538035Medicare PIN
480019276Medicare PIN