Provider Demographics
NPI:1912907445
Name:SMITH, DENISE M (DO)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 W STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3103
Mailing Address - Country:US
Mailing Address - Phone:260-422-0010
Mailing Address - Fax:260-422-2212
Practice Address - Street 1:1211 W STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3103
Practice Address - Country:US
Practice Address - Phone:260-422-0010
Practice Address - Fax:260-422-2212
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2021-11-02
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-17
Provider Licenses
StateLicense IDTaxonomies
IN02001605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200023850Medicaid
IN080175244OtherRAILROAD MEDICARE
INF63230Medicare UPIN
IN150640AAMedicare PIN