Healthcare Provider Details

I. General information

NPI: 1821020058
Provider Name (Legal Business Name): DOUGLAS S SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N84 W16889 MENOMONEE AVE
MENOMONEE FALLS WI
53051
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-251-7500
  • Fax: 262-251-7128
Mailing address:
  • Phone: 262-251-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27805
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: