Provider Demographics
NPI:1881658045
Name:SMITH, THOMAS PAUL (D C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:SMITH
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 E RACINE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6462
Mailing Address - Country:US
Mailing Address - Phone:262-832-8888
Mailing Address - Fax:262-806-0028
Practice Address - Street 1:W177N9856 RIVERCREST DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4647
Practice Address - Country:US
Practice Address - Phone:262-251-9300
Practice Address - Fax:262-251-9303
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2664111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI200879361018OtherBLUE CROSS BLUE SHIELD
WIP00110391OtherRAILROAD MEDICARE
WIU14010Medicare UPIN
WI200879361018OtherBLUE CROSS BLUE SHIELD