Healthcare Provider Details

I. General information

NPI: 1932928124
Provider Name (Legal Business Name): MR. JAMES MATTHEW SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

IV. Provider business mailing address

4605 FREDERICK PIKE APT C
DAYTON OH
45414-3938
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-1737
  • Fax:
Mailing address:
  • Phone: 937-272-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005507
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: