Healthcare Provider Details

I. General information

NPI: 1598534588
Provider Name (Legal Business Name): MR. DOMINIQUE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 01/01/2024
Certification Date: 01/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9511 PERRIN BEITEL RD APT 102
SAN ANTONIO TX
78217-3538
US

IV. Provider business mailing address

9511 PERRIN BEITEL RD APT 102
SAN ANTONIO TX
78217-3538
US

V. Phone/Fax

Practice location:
  • Phone: 713-393-9739
  • Fax:
Mailing address:
  • Phone: 713-393-9739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code211D00000X
TaxonomyPodiatric Assistant
License NumberNHA346213
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: