Provider Demographics
NPI:1811289853
Name:SMITH, THOMAS EDWARD (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
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 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:269 PORTLAND WAY S
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-2312
Practice Address - Country:US
Practice Address - Phone:419-462-3839
Practice Address - Fax:419-462-3840
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014734208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0419497Medicaid
MI1811289853Medicaid