Provider Demographics
NPI:1740091552
Name:SMITH, SHEDRICK EUGENE I
Entity type:Individual
Prefix:MR
First Name:SHEDRICK
Middle Name:EUGENE
Last Name:SMITH
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:SHEDRICK
Other - Middle Name:E
Other - Last Name:SMITH
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5625 N GERMAN CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-8513
Mailing Address - Country:US
Mailing Address - Phone:317-840-2637
Mailing Address - Fax:
Practice Address - Street 1:5625 N GERMAN CHURCH RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-8513
Practice Address - Country:US
Practice Address - Phone:317-840-2637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8918832028172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver