Provider Demographics
NPI:1831197052
Name:SMITH, DALE M (DPM)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:M
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 1:5405 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2349
Mailing Address - Country:US
Mailing Address - Phone:708-425-7476
Mailing Address - Fax:708-425-4223
Practice Address - Street 1:1030 N STATE ST APT 49B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2839
Practice Address - Country:US
Practice Address - Phone:312-810-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL016002624213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016002624Medicaid
IL016002624Medicaid
1831197052Medicare PIN
IL0325310001Medicare NSC