Healthcare Provider Details

I. General information

NPI: 1306830484
Provider Name (Legal Business Name): MICHAEL J SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TECHNOLOGY PARK DR
BOURNE MA
02532-8341
US

IV. Provider business mailing address

139 SANDWICH ST
PLYMOUTH MA
02360-2449
US

V. Phone/Fax

Practice location:
  • Phone: 508-743-9543
  • Fax: 508-743-8335
Mailing address:
  • Phone: 508-743-9543
  • Fax: 508-743-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number223770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: