Healthcare Provider Details

I. General information

NPI: 1962646786
Provider Name (Legal Business Name): CAROLYN MARION SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 N LAUREN LN
BLOOMINGTON IN
47404-9206
US

IV. Provider business mailing address

3620 N LAUREN LN
BLOOMINGTON IN
47404-9206
US

V. Phone/Fax

Practice location:
  • Phone: 317-697-7607
  • Fax: 317-574-0050
Mailing address:
  • Phone: 317-697-7607
  • Fax: 317-574-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number01027170
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: