Provider Demographics
NPI:1740282409
Name:SMITH, DAVID (DPM)
Entity type:Individual
Prefix:
First Name:DAVID
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 1:56 BENJAMIN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1628
Mailing Address - Country:US
Mailing Address - Phone:616-456-9744
Mailing Address - Fax:616-451-0717
Practice Address - Street 1:56 BENJAMIN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1628
Practice Address - Country:US
Practice Address - Phone:616-456-9744
Practice Address - Fax:616-451-0717
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001622213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4461768Medicaid
MI4461768Medicaid
MIU25165Medicare UPIN