Healthcare Provider Details

I. General information

NPI: 1750814869
Provider Name (Legal Business Name): ANTONIO SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST # 2E
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST # 2E
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4832
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01084090
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: