Healthcare Provider Details

I. General information

NPI: 1134125511
Provider Name (Legal Business Name): CHRISTIAN CHARLES SMITH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8055 CLUB PKWY
CORDOVA TN
38016-5967
US

IV. Provider business mailing address

8055 CLUB PKWY
CORDOVA TN
38016-5967
US

V. Phone/Fax

Practice location:
  • Phone: 901-309-7700
  • Fax: 901-507-3297
Mailing address:
  • Phone: 901-309-7700
  • Fax: 901-507-3297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number672
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3350006
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: