Healthcare Provider Details

I. General information

NPI: 1154349900
Provider Name (Legal Business Name): LATISHA A SMITH-CHASE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LATISHA SMITH M.D.

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DOCTORS CT
JOHNSON CREEK WI
53038-9567
US

IV. Provider business mailing address

PO BOX 249
FORT ATKINSON WI
53538-0249
US

V. Phone/Fax

Practice location:
  • Phone: 920-699-4000
  • Fax:
Mailing address:
  • Phone: 920-563-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number73794-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number73794-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: