Healthcare Provider Details

I. General information

NPI: 1316239361
Provider Name (Legal Business Name): DAVID IAN SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 UPLAND LN N
MAPLE GROVE MN
55369-4485
US

IV. Provider business mailing address

8170 33RD AVE S
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number59986
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: