Provider Demographics
NPI:1396298642
Name:SMITH, PAUL (DPM)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 55TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-2267
Mailing Address - Country:US
Mailing Address - Phone:708-352-5652
Mailing Address - Fax:708-482-7465
Practice Address - Street 1:915 55TH ST STE 200
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-2267
Practice Address - Country:US
Practice Address - Phone:708-352-5652
Practice Address - Fax:708-482-7465
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005833213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty