Provider Demographics
NPI:1972588150
Name:SMITH, DANIEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 WHITNEY CT
Mailing Address - Street 2:CENTRA CARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1899
Mailing Address - Country:US
Mailing Address - Phone:320-251-1755
Mailing Address - Fax:507-434-1477
Practice Address - Street 1:1520 WHITNEY CT
Practice Address - Street 2:CENTRA CARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1899
Practice Address - Country:US
Practice Address - Phone:320-251-1755
Practice Address - Fax:507-434-1477
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN340757800Medicaid
MN080140250OtherMEDICARE RAILROAD
MN340757800Medicaid
MNG48242Medicare UPIN