Healthcare Provider Details

I. General information

NPI: 1982600615
Provider Name (Legal Business Name): CHAD J. SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 SCHNUCKS DR STE B
WARRENTON MO
63383-1121
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 636-456-3413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2003015262
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: