Provider Demographics
NPI:1255365565
Name:SMITH, EDWARD B (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3289 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3203
Mailing Address - Country:US
Mailing Address - Phone:414-771-7900
Mailing Address - Fax:414-607-6336
Practice Address - Street 1:3289 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3203
Practice Address - Country:US
Practice Address - Phone:414-771-7900
Practice Address - Fax:414-607-6336
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI25439208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31706400Medicaid
WIP00465794OtherRR MEDICARE
WI01994-0250Medicare PIN
WI46236-0250Medicare PIN
WIP00465794OtherRR MEDICARE