Provider Demographics
NPI:1457368862
Name:SMITH, GARY S (DPM)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
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 1:133 MILL ST
Mailing Address - Street 2:PO BOX 804
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1408
Mailing Address - Country:US
Mailing Address - Phone:814-362-3668
Mailing Address - Fax:814-362-0540
Practice Address - Street 1:133 MILL ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1408
Practice Address - Country:US
Practice Address - Phone:814-362-3668
Practice Address - Fax:814-362-0540
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003540L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012260110002Medicaid
U02246Medicare UPIN
PASM618477Medicare ID - Type Unspecified