Healthcare Provider Details

I. General information

NPI: 1962617845
Provider Name (Legal Business Name): EDWARD LAWRENCE SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 N TAYLOR DR
SHEBOYGAN WI
53081-3043
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-3257
  • Fax:
Mailing address:
  • Phone: 920-457-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101016859
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number55826-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: