Healthcare Provider Details

I. General information

NPI: 1093336943
Provider Name (Legal Business Name): DONALD BROCK SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

8701 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7387
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number81799-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: