Provider Demographics
NPI:1700101102
Name:SMITH, MITCHELL W (DO)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:965 EMERSON PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6273
Practice Address - Country:US
Practice Address - Phone:317-865-0055
Practice Address - Fax:317-865-0056
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004276A207K00000X, 207KA0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1127019OtherMEDICARE PTAN
ININ1125020OtherMEDICARE PTAN
IN201095070Medicaid