Healthcare Provider Details

I. General information

NPI: 1861498669
Provider Name (Legal Business Name): CHARLES A SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S CODY RD
LE CLAIRE IA
52753-9579
US

IV. Provider business mailing address

865 LINCOLN RD STE L10
BETTENDORF IA
52722-4159
US

V. Phone/Fax

Practice location:
  • Phone: 563-289-3008
  • Fax: 563-289-3024
Mailing address:
  • Phone: 563-355-9191
  • Fax: 563-355-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02372
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: