=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063774214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL AUGUSTUS SMITH D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2012
-----------------------------------------------------
Last Update Date | 06/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 W HWY 6 SUITE 111
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76710-5591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-752-9621
-----------------------------------------------------
Fax | 254-752-8378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21509
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76702-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-752-9621
-----------------------------------------------------
Fax | 254-752-8378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0500X
-----------------------------------------------------
Taxonomy Name | Cytopathology Physician
-----------------------------------------------------
License Number | P0499
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | P0499
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------