Healthcare Provider Details

I. General information

NPI: 1659355089
Provider Name (Legal Business Name): DAMON LAMONT SMITH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 S LYNHURST DR STE 707
INDIANAPOLIS IN
46241-8605
US

IV. Provider business mailing address

5412 NIGHTHAWK DR
INDIANAPOLIS IN
46254-3712
US

V. Phone/Fax

Practice location:
  • Phone: 800-317-0711
  • Fax: 800-434-7113
Mailing address:
  • Phone: 317-297-5940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000969A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: