Healthcare Provider Details

I. General information

NPI: 1558628396
Provider Name (Legal Business Name): DIONNE VANESSA SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W. CURTIS RD.
CHAMPAIGN IL
61822-9678
US

IV. Provider business mailing address

303 G H BAKER DR
URBANA IL
61801-1160
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6202
  • Fax: 217-326-0188
Mailing address:
  • Phone: 217-326-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036138395
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: