Provider Demographics
NPI:1831142074
Name:SMITH, JOANNE CARLA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:CARLA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1198
Mailing Address - Country:US
Mailing Address - Phone:218-879-1271
Mailing Address - Fax:218-879-8904
Practice Address - Street 1:275 JAY COOKE RD
Practice Address - Street 2:
Practice Address - City:ESKO
Practice Address - State:MN
Practice Address - Zip Code:55733-9727
Practice Address - Country:US
Practice Address - Phone:218-391-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN708820500Medicaid
MNG82383Medicare UPIN