Healthcare Provider Details

I. General information

NPI: 1982831160
Provider Name (Legal Business Name): STEFANIE ANN SMITH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 N KEYSTONE AVE SUITE 100
INDIANAPOLIS IN
46218-2789
US

IV. Provider business mailing address

3403 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-957-2300
  • Fax: 317-957-2320
Mailing address:
  • Phone: 317-957-2000
  • Fax: 317-957-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301094662
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301094662
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: