Provider Demographics
NPI:1952357287
Name:SMITH, TIMOTHY S (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 S SAINT LOUIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2924
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:121 S SAINT LOUIS BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2924
Practice Address - Country:US
Practice Address - Phone:574-233-3123
Practice Address - Fax:574-233-3125
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041614A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN736860RMedicare PIN
ING25512Medicare UPIN
IN187390MMedicare PIN