Provider Demographics
NPI:1831281724
Name:SMITH, MARK W (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-2807
Mailing Address - Country:US
Mailing Address - Phone:205-758-7158
Mailing Address - Fax:205-758-7166
Practice Address - Street 1:2601 12TH ST
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2807
Practice Address - Country:US
Practice Address - Phone:205-758-7158
Practice Address - Fax:205-758-7166
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1608OtherLICENSE NUMBER
AL1608OtherLICENSE NUMBER
ALU53972Medicare UPIN