Healthcare Provider Details

I. General information

NPI: 1093137218
Provider Name (Legal Business Name): MR. SHAWN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 E LARNED ST
DETROIT MI
48207-3905
US

IV. Provider business mailing address

2971 E LARNED ST
DETROIT MI
48207-3905
US

V. Phone/Fax

Practice location:
  • Phone: 131-382-9965
  • Fax:
Mailing address:
  • Phone: 131-382-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: