Healthcare Provider Details

I. General information

NPI: 1043245376
Provider Name (Legal Business Name): DANIEL M SMULLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 W LINCOLN AVE 2ND FL
WEST ALLIS WI
53227-2409
US

IV. Provider business mailing address

8901 W LINCOLN AVE 2ND FL
WEST ALLIS WI
53227-2409
US

V. Phone/Fax

Practice location:
  • Phone: 414-329-4300
  • Fax:
Mailing address:
  • Phone: 414-329-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46773-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: