Provider Demographics
NPI:1649611252
Name:SMITH, CHARLI WALTER LEROY JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLI
Middle Name:WALTER LEROY
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:7209 MOAKE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7782
Mailing Address - Country:US
Mailing Address - Phone:262-488-2395
Mailing Address - Fax:
Practice Address - Street 1:608 ROLLIE MOORE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2351
Practice Address - Country:US
Practice Address - Phone:618-252-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361390192083P0011X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE GROUP